Elements Magazine Vol. 10 Iss. 3 September 2021

PILLS TO PRISON Millions are incarcerated — and they need meds

SECOND BEST New survey reveals top trends in secondary market purchasing

MAKING THE TRANSITION Transitions of care is a win-win for pharmacies and hospitals

VOL. 10 ISS. 3 | SEPTEMBER 2021

Resources Buying a Pharmacy Checklist

Loan Calculators

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Podcasts

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22

CONTENTS ON THE COVER

22 FEATURE

| Making the Transition

Transitions of care is a win-win for pharmacies and hospitals

DEPARTMENTS

06 NEWS

| You Have the Right

New guidelines from major pharmacy organizations address pharmacist rights and responsibilities

08 TRENDS

FEATURE | Making the Transition

| Second Best

New survey reveals top trends in secondary market purchasing

16

10 RETAIL

| The Silent Salesperson

Essential merchandising tactics to increase retail sales

14 SOLUTIONS

| Injectables in Action

An inside look at the opportunity of long-acting antipsychotic medications

16

18

SPOTLIGHT | Pharmacy's New Best Friend Pet medicine is a treat to this pharmacy’s business

MONEY | Planning for Success A lawyer’s guide to succession planning

30 OUTLOOK

| Pills to Prison

Millions are incarcerated—and they need meds

ELEMENTS | The business magazine for independent pharmacy | SEPTEMBER 2021

SPOTLIGHT | Pharmacy's New Best Friend

3

E

ON THE WEB

ELEMENTS

The business magazine for independent pharmacy

VOLUME 10, ISSUE 3

Find more strategies, tips, and expert advice to improve your business.

SEPTEMBER 2021 PUBLISHER & EDITORIAL DIRECTOR Matthew Shamet EDITOR Greyson Honaker SR. ART DIRECTOR Brenda Reagan

5 Demographic Trends Shaping the Future of Pharmacy Use these five emerging U.S. trends to guide the selection of products, services, and offerings in your pharmacy.

CONTRIBUTING WRITER Erin E. Rand

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How to Be an Extraordinary Manager Learn the most important management tips from the book Becoming an Extraordinary Manager: The Five Essentials for Success.

9 Tactics to Win Any Negotiation An FBI Hostage Negotiator reveals his most effective negotiation strategies every business can use.

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Neither this publication nor any part of it may be reproduced without written permission by PBA Health.

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NEWS

YOU HAVE THE RIGHT New guidelines from major pharmacy organizations address pharmacist rights and responsibilities

T

he coronavirus pandemic amplified for the public a reality already well-known to pharmacists: they give everything for

their patients no matter what it takes, even at the expense of their own well-being. Even before the pandemic, this truth was so

PHARMACIST'S FUNDAMENTAL RESPONSIBILITIES AND RIGHTS

pervasive that it spurred five of the largest pharmacy organizations to convene in 2019 and devise 50 recommendations aimed at

Pharmacist's Fundamental Responsibilities and Rights

reducing the mental and physical burdens belaboring pharmacists.

details five fundamental pharmacist responsibilities and

seven fundamental rights. For the full document go to

The recommendations came on the heels of similar initiatives

introduced in state congresses across the country in recent years,

pharmacist.com/pharmacistsresponsibilities.

with legislators advocating bills to limit pharmacist work hours and enforce routine breaks throughout the day.

This year, the APhA and the National Alliance of State

Pharmacy Associations (NASPA) continued the work from that conference and created another document that ″develops actionoriented activities based on a number of these recommendations,″ said Joni Cover, JD, vice president of strategic initiatives at NASPA. ″Pharmacists are tremendous healthcare providers. They need workplace changes such as appropriate staffing, and support that allows them to provide the best possible care to their patients.″

The document, Pharmacist's Fundamental Responsibilities and

Rights, aims to guide basically everyone involved in pharmacy, from store clerks to governing authorities. ″The principles in the

5 FUNDAMENTAL RESPONSIBILITIES 1. To practice with honesty and integrity.

2. T o seek employment that aligns with their professional goals and personal values and needs.

3. To be lifelong learners to maintain professional competency and engage in the profession.

4. To educate their patients and the public to enhance public health.

5. To make decisions and seek resolutions regarding workplace concerns without fear of intimidation or retaliation from their employer or supervisors.

Fundamentals document were developed for all who practice pharmacy and care for patients, irrespective of the practice site, to ensure that the practice setting provides a positive, welcoming, and professional place to practice and care for patients,″ Cover said.

For pharmacists in particular, the hope is they will ″engage

supervisors and managers in a meaningful discussion about their workplace and issues surrounding workplace well-being, both the good and the bad, that lead to overall improvement in workplace environments plus improved well-being for employees,″ Cover said.

For pharmacy managers and owners, the hope is to use the

guide to ″have a discussion with your pharmacists and pharmacy personnel. Be willing to hear their concerns and ideas for improving the workplace.″

For governing authorities, the hope is to make changes to laws

and regulations causing undue administrative burdens, allowing pharmacists to focus on patient care.

Most of all, NASPA wants this document to encourage

7 FUNDAMENTAL RIGHTS 1. To practice pharmacy in the best interest of patient and community health and well-being.

2. T o exercise professional judgment under the auspices of their license when delivering care to patients.

3. To be treated in a considerate, respectful, and professional manner by patients and supported by employers and supervisors. o a workplace free of racism, discrimination, 4. T bullying, or harassment, as well as physical, verbal, or emotional abuse.

5. To a working environment where the necessary resources are allocated to provide both legally required patient care services, as well as any additional enhanced patient care services offered.

pharmacists to advocate for themselves. ″The takeaway for

6. To reasonable working hours and conditions.

pharmacists,″ Cover said, ″is that it is important to continue to

7. To have a voice in the development of metrics, and how those metrics are used as criteria for performance evaluations of all pharmacy staff.

make your voice heard.″

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ELEMENTS | The business magazine for independent pharmacy | SEPTEMBER 2021

7

TRENDS

SECOND BEST

New survey reveals top trends in secondary market purchasing

M

ost independent pharmacies are under contract with a primary wholesaler, most of which carry enough product to

fully stock a pharmacy of any size. Even so, there are more than a

price on the items they're looking for, which are often medications with narrow margins. ″If we have a certain medication that we're constantly losing money on from our wholesaler, then we look for

hundred secondary suppliers in business who serve independents

that one,″ Glover said.

every day.

Although Meyer will search for a good deal, he often returns to

Elements magazine surveyed its readers to discover why they

the supplier with consistently low prices. ″It's just going back to the

venture into the secondary market and what exactly they're looking

ones that we know are going to be a lower price,″ he said.

for. Nearly every respondent said they have a primary wholesaler,

and all but four of them buy outside of their primary contract.

Drugs, navigates a handful of suppliers depending on whether

he's looking for brands, short-dated items, or savings on large

Of those pharmacies, 93 percent buy generics from

Charles Canvasser, owner of the Pharmacy at Westland Maple

secondaries and 59 percent buy brands. However, the vast majority

purchases. In almost all cases, he's only going out to the secondary

of their total purchases still go through their primary. On average,

market for items with big price tags. ″I don't have enough hours

secondary purchases make up about 20 percent of their total

in the day to sit and pick and choose an item that's $1.17,″ he said.

generic inventory and 13 percent of their total brand inventory.

About 70 percent of respondents said they use secondaries

″I'm looking for some significant dollars.″ When he does land a good deal, it saves him a lot. He's found a difference of $100 among

because an item is too costly at their primary wholesaler. Nearly 60

suppliers for a medication that's typically more than $300.

percent listed low reimbursement as a main reason for purchasing

outside of their primary contract.

because they don't want to ruin their rebates from their primary,

″Some of these insurance reimbursements are terrible,″ said

Both Canvasser and Glover restrict the amount they purchase

which are based on volume. ″If I'm going to deviate from them, it

Brian Meyer, owner of Sunflower Rx. ″I always have to look for the

needs to be something that's going to give me at least a 20 percent

best price to just to break even.″

difference,″ Canvasser said.

When asked which secondaries they use, the pharmacies

identified 43 different suppliers in total. The top three "best"

2

choices were BuyLine, Anda, and IPC, with price, customer service, and product availability cited as the main reasons.

Here's a breakdown of five key takeaways on how independent

pharmacies navigate the secondary supplier market.

LOOK FOR OUT-OF-STOCK ITEMS

Seventy percent of pharmacies seek out a secondary because their primary doesn't have the item they need. This can occur for a variety of reasons, whether it's a shortage or pre-allocation

1

SEARCH FOR BEST PRICES

Far and away, pharmacies go to the secondary market to find better pricing. When they aren't getting the best cost from their primary wholesaler, they seek out secondaries for a better deal.

″When they have specials or a really good price, they're

anywhere from 20 to 50 percent off what we normally would pay,″ said Bryon Glover, pharmacy director at Hoover Drug, Eufaula

prioritizing chain pharmacies.

″Every once in a while, a particular medication will be on back

order and you just can't get it,″ Glover said. ″I don't think there's really any rhyme or reason that we've seen.″

In these cases, pharmacies often first go to the secondary

suppliers that ″always have item in stock″ or ″have a comprehensive inventory″ or ″often have the missing item,″ according to the responses.

Pharmacy, and Checotah Pharmacy.

The amount they save sometimes depends on how much time

they're willing to spend searching. ″If we do a lot of shopping, we

3

CARE ABOUT CUSTOMER SERVICE AND SUPPORT

can sometimes save even hundreds of dollars over what it would cost at our primary wholesaler,″ Meyer said.

Although price and availability drive the majority of secondary

purchases, many pharmacies choose their secondary based on

Among the reasons pharmacies choose a particular secondary

supplier, just over 80 percent opt for the one offering the best

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their customer service and support.

″If I've got a problem that's not getting taken care of right away, that

to use EDI to make ordering easier, which indicates a lack of EDI

would be grounds for me to not use them,″ Canvasser said. ″I don't

integration among secondary suppliers.

need to tie my money up with them.″

I wish had that capability,″ Meyer said. For the suppliers that do

Many pharmacies chose a supplier for their recent purchases

″The EDI seems somewhat limited still, and there are some

because they were ″easy to work with″ or had ″exceptional

integrate with his pharmacy system, he'll use EDI to compare prices.

customer service.″

Pharmacies order from secondary suppliers at least once

per week, and some order every day. Among four choices— pharmacist-in-charge, pharmacist, technician, owner—pharmacistin-charge was the role most often responsible for ordering the inventory. Pharmacists came in second, followed by technicians.

The top three ″best″ choices were BuyLine, Anda, and IPC, with price, customer service, and product availability cited as the main reasons.

However, the total was nearly even among all four.

5

NEED FREE NEXT-DAY SHIPPING

Supplier shipping policies vary considerably. Some offer free shipping after a minimum purchase amount while others only offer two-day shipping at best.

About 40 percent of respondents listed free shipping as a

reason they choose any secondary source.

″If I'm not getting next-day shipping, I'm not ordering,″

Canvasser said. He's found that the minimum order from most suppliers is around $150. If he doesn't have enough volume to One negative trend was the frustration of getting daily phone calls from sales reps. ″Some of them actually call once a day, every day,″

reach that amount, then it's not worth ordering from a secondary in the first place, he said.

Glover said. ″I don't have time to take all these sales calls every day.″

Some suppliers have found better ways to inform their customers

of good deals and items in stock than pelting them with calls. ″I prefer an email where I can look at their specials,″ Glover said.

Canvasser prefers to find them himself online. ″I'd rather go

to the internet and have a few companies that I deal with. If I need to, I'll find the best price,″ he said. ″Specials don't mean anything to me because that's how they hook you into buying more. I want everyday prices.″

4

WANT EASY ORDERING

Most pharmacies want to order online rather than on the phone, and they want to be able to compare up-to-date prices and search easily on the website.

Canvasser almost exclusively orders online, and ease of use is

the most important part of the experience. ″That's the big deciding

10 POPULAR SECONDARY SUPPLIERS When asked which secondaries they use, the survey respondents identified 43 different suppliers in total.

Below are 10 that were the most cited.

1. BuyLine 2. Anda 3. IPC 4. ParMed 5. Trxade

6. TopRx 7. KeySource 8. Smith Drug 9. Auburn 10. IPD

factor,″ he said. ″Simplicity of being able to order and look up prices is most important.″

Meyer wants the website to clearly show the pricing details, like

cost per tablet or cost per pill. ″The ones that have more information or are easier to navigate are the ones I order through most.″

Although many pharmacies use an electronic data interface

(EDI) for their primary wholesaler, the vast majority do not use it to order from secondary suppliers. However, many want the ability

ELEMENTS | The business magazine for independent pharmacy | SEPTEMBER 2021

9

RETAIL

THE SILENT SALESPERSON Essential merchandising tactics to increase retail sales

I

t's not enough to have the products your patients want. To get the most out of your inventory, you have to display it in a way that

persuades shoppers to buy more.

The art of arranging your inventory is known as merchandising.

Merchandising creates opportunities to turn more inventory, and unlike discount promotions, it doesn't cut into your profit margins. ″The reality is that all that merchandise sitting on your floor is your money sitting there," Phibbs said. "You only make money if the

Whether patients are looking through the store window or

merchandise turns over. Otherwise, you're just filling up your store

browsing the aisles, you can make sure patients know how to find

and your merchandise isn't giving you a return on investment."

the staple pharmacy products they expect and introduce them to statement products they may not have considered.

″The main goal is to connect the customer to the products

and services you sell, and it has many touch points,″ said Nicole Leinbach Reyhle, founder of the retail publication Retail Minded and author of the book Retail 101: The Guide to Managing and Marketing Your Retail Business. "You want your inventory to be as strategically understood within your store environment by customers as it can be, and merchandising allows you to do that."

Bob Phibbs, retail expert and founder of the Retail Doctor, sees

merchandising as a ″silent salesperson″ in the pharmacy. ″It's how you scratch the itch of a casual customer,″ he said. ″If a customer is waiting for a prescription, merchandising can help them discover

STAPLES VS. STATEMENTS Nicole Leinbach Reyhle, founder of the retail publication Retail Minded, encourages retailers to think of their products in terms of staples and statements.

Staples are your standards. "Milk is a staple item," said Reyhle. "But a statement item would be something more like oat milk or almond milk."

something they didn't even know they wanted.″ If someone comes in to buy conditioner but stops and looks at your carefully curated display, they might leave with more items in their basket than they came in for.

Merchandising comprises a wide range of strategies. You

Pair a staple with a statement to introduce your patients to products they may not have considered. If patients frequently come in for bandages, display them alongside a specialty wound care product.

might put impulse buys next to your cash register or place the most sought-after products in the back of the store to encourage customers to see the other items on the shelves. "Merchandising efforts don't fall directly under a specific sales category,″ Reyhle said. ″The goal is to optimize your sales through inventory.″

It’s super important to understand how the average consumer views your store versus how you see your store.

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BREAK UP YOUR SPACE do it. "Take your camera and take pictures. You'll start to notice

Reyhle recommends dividing your store's space into categories. ″Where your customers check out, where they engage with inventory,

how they group things together," he said. "You just have to be curious as to why stores put things where they do."

or any other landing spot to make them spend more time in one place," she explained. Use your point-of-sale system to separate each part of the store and track your merchandising efforts for each area. Investigate which products are succeeding, then use that information to optimize your merchandising strategy and get ideas for cross-promoting your products. ″You may even consider applying

A customer needs to be able to understand your inventory and how they can actually make a purchase.

sales goals within each of those spaces," Reyhle said.

Phibbs suggests thinking of how different products fit together

to tell a story. You could put shampoo and conditioner, hair dryers, and hot oil treatments in different aisles, but when you put them all together in a display announcing "The Complete Solution for Frizzy Hair," you create a much bigger impact. "Customers who need that and see the display will know they should buy all those items," Phibbs said.

In addition to thinking about how products are divided up

within your store, consider where products are placed on the shelves. Generally, products above eye level and below the waist won't sell as well. "Take greeting cards, for example," Phibbs said.

"You're going to put your most expensive greeting cards between

Don't be afraid to get creative. A few inexpensive props can make

the navel and the chin, because that's where most people are going

a display stand out. "If you're doing a display for window cleaning

to look first."

supplies, choose a few complementary products and place them

KILLER DISPLAYS

really quickly—this is everything they need to clean their windows,"

Just putting the right products on the right shelves won't necessarily

Phibbs said. "And then say something like, 'Make sure you can see all

improve your sales and profits. Create a display that catches your

the spring flowers this year,' because that adds to the point of view."

inside a cheap dollar store frame. Add a squeegee so people get it

customers' attention by putting yourself in their shoes.

Use contrasting colors to add intrigue to the display.

"I always say, 'Look up, look down, look left, look right,' because

What you choose to display is just as important as how you

that is what the customer is doing," Reyhle said. "Ask yourself how

display it. The products you highlight should be large enough to

you're visually supporting them. Are you offering them navigation

catch the eye, because if you try to call attention to something the

that helps them get where they want to go without having to

size of a deck of cards, people might miss it.

communicate directly with you?"

together takes time and money, so choose items that have a

If you're not sure where to start with creating a display, Phibbs

recommends visiting a big box competitor to scope out how they

You should also think about the price point. Putting a display

decent margin to make the display worthwhile.

INTEREST

RETENTION

FINISH START

AWARENESS

PURCHASE

ADVOCACY

11

SIGNAGE SECRETS Communicating with your patients with signage is also a crucial part of merchandising. ″We really want to consider all touch points

THE 4 Cs OF COMMUNICATION

in which the customer engages through your signage,″ Reyhle said. ″And that's going to ultimately lead your customers through a directional experience of your store.″

Like with your displays, Reyhle recommends owners apply the

When merchandising products at the pharmacy,

same "up, down, left, right" mentality. "How much signage you have

Reyhle encourages pharmacists to remember the

depends on your square footage," she said. "Mostly, the goal here

4 Cs of communication:

is to make sure your customer is not confused. You want to keep

1. Clear

your customer on a path to purchase. Once they get off that path,

2. Concise

3. Correct

4. Courteous

you risk losing sales."

The messaging received by patients—whether

through signage or directly from a pharmacy staff

As for the content of your signs, Phibbs said the copy "should

be short and meaningful."

member—should be easy to understand and

delivered in a polite, nonjudgmental manner.

The appearance of the sign is just as important as the wording.

"The font should be large enough for people to actually read.

Consider the demographics of your audience. In a pharmacy, you may have clients whose eyes aren't as strong as they used to be," Reyhle said. "It may be easier for them to see bold, crisp letters rather than something like cursive."

Many pharmacies put signs on the floor during the coronavirus

pandemic to help patients maintain social distancing. These floor signs can still be useful to show people the best way to navigate your store, Reyhle said.

MERCHANDISING MUSTS One of the most important parts of merchandising is ensuring it makes sense from the customer's point of view. "A customer needs to be able to understand your inventory and how they can actually make a purchase," Reyhle said. ″It's super important to understand how the average consumer views your store versus how you see

FALLING PRICES AHEAD

your store.″

Phibbs said to be intentional about which products you put

next to each other. "If you put too many products out at once, the merchandise doesn't relate to each other," said Phibbs. "It's just stuff on a table." Make sure everything is clearly labeled with a price because your patients won't buy something if they have to work to figure out the cost.

Don't overlook the small details, because you may be missing

out on opportunities that you hadn't ever thought of before. Reyhle said, "Pharmacists may want to challenge themselves to look at their receipts. Ask yourself, 'Is my return policy clear on the bottom of the receipt patients are getting?'" Every contact point with patients is a micro-opportunity to merchandise, so be sure to think about communication from many different angles.

Phibbs also warns against committing to a merchandising

strategy that's not working. If a merchandising effort is effective, you should see it right away. "People will be picking products up," he said. "If people aren't touching stuff, it's not working. You can usually see that within a day."

12

ELEMENTS | The business magazine for independent pharmacy | SEPTEMBER 2021

13

SOLUTIONS

INJECTABLES IN ACTION

An inside look at the opportunity of long-acting antipsychotic medications

W

hile pharmacists continue to wait for provider

several of his patients were looking for a place to get their

status, states continue to expand their scope

injections, he started carrying them. ″They used to pick up their

of practice one service at a time. In most cases, an

injection from Walgreens and CVS, and they didn't know what to

expansion of scope means an expansion of profit, and by

do with it. And they go to the doctors, and the doctors are busy,″

now most pharmacies have taken advantage by offering

he said. ″So patients approached us and we thought this would

nontraditional services like immunizations and point-of-

be a good opportunity.″

care testing. But pharmacies are still catching up on one

As with many other services, reimbursement varies across

overlooked opportunity to expand their scope and profit.

health plans, whether it's Medicare, Medicaid, or private insurers.

But in all, Zaibak said that the reimbursement for these drugs is

Recently, states across the country have

authorized the administration of long-acting

better than traditional prescription medications.

injectables (LAIs), which mostly comprise

antipsychotics such as Invega, Abilify, Aristada,

count, sometimes by a large margin. ″That patient doesn't just

and Risperdal. For patients, the ability to get these

give us their injectable prescription,″ Zaibak said. ″When they

Just as important, offering LAIs helps increase your total script

injections at the pharmacy can be life changing.

transfer it to us, they transfer their whole profile.″

Pharmacies are easily accessible and help increase

In addition, you can earn an administration fee for each

adherence, which is essential for patients on

injection, paid for by a manufacturer or by the patient. Bremo and

antipsychotic meds.

Hayat both have patients who pay the fee out of pocket if they

aren't able to get patient assistance from the manufacturer.

″I feel it's important for pharmacists to be

involved with mental healthcare services,″ said Leighton N. Mascari, pharmacist at Bremo Pharmacy, which has served the Richmond, Virginia community since 1976. ″We've been able to offer different services to patients just by having them come through our doors and connecting them to care.″

Bremo Pharmacy has offered LAIs

for more than 20 years, when Virginia

Bremo Pharmacy is exploring alternative ways to get paid for the service. It recently established a collaborative practice agreement with a provider so the pharmacists can bill for their time. So far, this seems to be the best approach not only because it provides payment for the administration,

first gave pharmacists authority to

but also because it has

administer the drugs. The majority

opened the door for further

have been given at their long-term

services, like measuring

care location, where there has

blood pressure, weight,

always been a clear need. But

and waist circumference.

during the pandemic the retail

″That's really important for

location saw a large influx of LAI

the administration of LAIs

patients when psychiatric offices

because they can create a lot

stopped allowing patients to come

of metabolic effects,″ Mascari

in for administration. The pharmacy

said. ″And the providers have

now administers up to 25 LAIs a month on average.

Hashim Zaibak, owner of Hayat

Pharmacy, has provided LAIs for about three

been very excited that we do that.″ They also perform Abnormal Involuntary Movement Scale (AIMS) assessment to monitor for extrapyramidal

years and is already administering up to 30

side effects and involuntary movements that

injections every month. After discovering that

can occur with the long-term use of LAIs.

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KEYS TO SUCCESS Electronic care plans have been instrumental in Bremo's LAI

Unless you get buy-in from the staff, it's going to be a difficult road.

offering. ″E-care plans are very helpful for documentation and

″That's not just true with this project but with any project you do,″

follow up with providers,″ Mascari said. If a patient has an adverse

Zaibak said. ″If you get employees who really care, you can make

side effect or has questions the pharmacy can't answer, they can

this a very successful project.″

document it in the plan for the provider. The e-care plan also

Part of Hayat's success hinges on the reputation it has built in

keeps track of appointments, so pharmacists are prepared and

the community over time. Manufacturers, patients, and providers

make sure patients don't miss their injection. ″In this population,

have come to regard the pharmacy highly, which means they

adherence is not always easy,″ she said. ″So keeping up with

readily recommend Hayat for the healthcare services that matter.

patients and knowing when they're due for their medications is

Part of that reputation has come from the lengths they go for their

very important.″

The pharmacy also leans on other technology, like their

patients, like driving to patients' homes to administer the injections. ″People know that we care, that we're willing to go the extra mile,

HIPAA-compliant scheduling system that automatically texts

literally,″ Zaibak said. ″It's a win-win relationship. We help them and

reminders to patients.

they help us.″

Medication synchronization significantly helps protect cash

Bremo Pharmacy also has great relationships with prescribers

flow even when carrying LAIs, which can be expensive. Although

because of how thoroughly they take care of their patients and how

Bremo keeps some LAIs in stock based on prescribing patterns, it

consistently they improve outcomes. ″We've had some patients

primarily orders when the patient is due to pick up their medications

that are historically not adherent to the medications become more

for the month, making it easy to align inventory with demand.

adherent through their relationship with us,″ Mascari said. ″I take

extra time to check on how they're doing personally.″

It's the same at Hayat Pharmacy. The scheduled maintenance

combined with synchronization minimizes the holding costs even for the most expensive of these drugs. ″After a while you get to

REQUIREMENTS

know some of the fast movers and you can keep some of those

To administer the injectables, you'll need a separate room. ″You do

on the shelf, but also at the same time those medications are

need the private area because sometimes it goes into the gluteal

administered every four weeks, every six weeks, every eight weeks

part of the body,″ Zaibak said.

so they're not really an emergency,″ he said. ″You don't really have

to keep a large quantity in stock.″

subtle differences in the preparation and administration,

Although all the drugs are intramuscular, there may be

such has how long or how strongly to shake it. Mastering the different requirements simply takes a few minutes online. ″The manufacturer websites are phenomenal,″ Zaibak said. ″You watch a video and usually within a minute you'll know how to do it.″

If you get employees who really care, you can make this a very successful project.

Every pharmacy should check with their state board of

pharmacy to see if they have authority to administer LAIs. At least 11 states do not, and 4 require a collaborative practice agreement.

MORE TO KNOW In the time Zaibak has been offering LAIs, he's often encountered a fear of working with patients who are on antipsychotic medications, with a particular concern for safety. ″The fear is invalid,″ Zaibak said. ″The safety concern is exactly the same with patients who need these medications versus patients who don't need these medications.″

Mascari said she wished she knew that LAIs were such a need in

her community retail locations before the pandemic revealed it. ″We wish we had started this service a long time ago,″ she said. ″We feel that it would have benefited even more patients over the years.″ Mascari said educating employees is paramount, especially for these types of medications. ″Working in mental healthcare, you have to know that you're serving a different variety of patients.″ Staff should have a good understanding of the antipsychotic

But even in the brief time she's offered LAIs at Bremo

Pharmacy's retail locations, it's been more than worth it. ″It's been a very rewarding service for us as pharmacists and for the patients, being able to help them.″

medications, such as their varying intervals, and they should know what to do if they can't answer a question or if a patient misses their appointment.

ELEMENTS | The business magazine for independent pharmacy | SEPTEMBER 2021

15

SPOTLIGHT

PHARMACY'S NEW BEST FRIEND Pet medicine is a treat to this pharmacy’s business

M

ichael LeMasters has always had a heart for animals,

access to these products,″ LeMasters said. ″It's

especially for rescue dogs. His closest companion is a pocket

a matter of a pharmacy manager talking to the

pitbull named Stella, but he likes to call her Shadow because she

wholesaler and saying, 'Can you help me out with this?'″

never leaves his side.

considered the Big Three in the veterinary world. ″With a little bit

″My dogs have always been the center of my life,″ he said. So

it was only natural for the owner of Pierpont Landing Pharmacy

He said there are animal med wholesalers that could be

of research, a pharmacy owner can figure out who those are and

in Morgantown, West Virginia, to start treating the furry members

reach out to them.″

of the family along with their humans. ″You're taking care of the

community as it is. Why not afford their pets the same level of care?

People are still adjusting to the idea of getting meds from

Why not take care of the entire family?″

pharmacies rather than veterinarians. It took some convincing for

patients who have been getting theirs from the same place for so

The service is a huge benefit to patients who otherwise might

Getting started was the toughest part for Pierpont Landing.

not be getting the kind of care that only a community pharmacy

many years. Pet owners also like the convenience of delivery from

can provide. ″It can be a tremendous asset to the community

online pharmacies and didn't realize Pierpont Landing would deliver.

because it's a patient population that is often served by online

″We have had a lot of conversations, and we did a lot of

pharmacies,″ LeMasters said.

marketing,″ he said. Eventually, he broke through. ″As the service is

advertised and as you build that relationship in the community, you

When he began offering veterinary medicine 10 years ago,

he didn't know of any other community pharmacies doing it.

take care of one pet owner who then turns around and tells their

And even now, he wonders why more haven't hopped on board.

friend what you did for them and they tell their friends.″

″There's a ton of opportunity out there for pharmacies. If you

aren't doing it, why not?″

Once he got started, incorporating the meds into his workflow

was straightforward. ″The orders are treated the same. You're

Pet prescriptions circumvent the greatest cause

doing the same virtualization review, the same allergy checks, the

of pharmacy profit woes. All of them are

same QA process that you're going to do on any prescription that

paid for with cash. ″There's no switch fee,

rolls through your pharmacy,″ LeMasters said.

no DIR fee, any of these clawback fees,″ LeMasters said. ″That alone is worth it.″ Pet meds allow you to substantially grow your patient base with very little work and investment. Not only do you get new business from additional family members of

St

el

la

your current patients, but you also attract new patients who are looking for better service and more affordable meds for their animal companions.

UP AND RUNNING Because pet meds were exclusively dispensed at veterinary offices for so long, finding a supplier willing to sell them to pharmacies used to be the greatest challenge. But as the market has opened up, access has become easier. ″Many of the wholesalers that pharmacies deal with day in and day out are starting to have more

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5 BEST-SELLING PET MEDS AT PIERPONT LANDING PHARMACY 1. Prednisolone (Prednistab) tablets 2. Pimobendan (Vetmedin) chewable tablets 3. Carprofen chewable tablets 4.

Deracoxib (Deramaxx) chewable tablets 5.

Grapiprant (Galliprant) tablets

CROSSOVER MEDS

Having built relationships with veterinarians and pharmacies in the area, the pharmacy will

This category of drugs serves both human and animal patients at different doses.

connect patients with someone to provide any medications they can't—so they always receive the care they need. ″It's not just one of those

• Enalapril • Gabapentin • Furosemide • Zonisamide • Phenobarbital

unfortunate circumstances where they feel like the door gets shut in their face,″ he said. ″We try to always have an answer. Either we take care of it or refer the owner to somebody who can.″

• Omeprazole • Fluoxetine • Doxycycline • Ondansetron • Tramadol

SUCCESS STRATEGIES As LeMasters frequented the veterinary office for his dogs, the vet educated him on animal health and animal pharmacology, which led to LeMasters into this new world of medication. He researched, took continuing education courses, investigated state and federal regulations, and talked to more veterinarians. ″I started to ask all these questions and found out there were a lot of ways to get into this realm of patient care for this other sector of the community.″

Along the way, he discovered ″a big opportunity.″ There are

several human medications that can also treat animals at the right doses. LeMasters refers to these as crossovers: ″One bottle for two populations.″ That was an easy way to initially add an entire new patient base without altering inventory.

Before LeMasters established himself as a resource for pet

LeMasters recommends approaching your relationship to veterinarians the same as your relationship with prescribers. ″You're not going to make a recommendation that goes above and beyond what an MD, DO, PA, or nurse practitioner does,″ he said. ″You're going to call them and discuss it with them, and as a team, come up with a plan for your patient.″ Establishing these relationships is essential, but they have

medications, he was careful not to make himself a direct competitor

with veterinarians. Instead, he took a more collaborative approach.

taken a lot of work. ″The difficult part at first was the amount of

He asked them what they needed and how he could support

time you have to put into the networking and the relationship

them, specifically helping with items that frequently go out of date,

building to be able to have those one-on-one conversations with

rarely turn, or are on back order. ″You want to be an asset to the

your veterinarians,″ LeMasters said.

veterinarian. You don't want to be a liability,″ he said. ″It's how can

you build a relationship that benefits them?″

reaching out to local animal shelters and the humane society. He

He has also found compounding to be a good entry to the

In addition to marketing, LeMasters grew his patient base by

found the most success throwing fundraisers with them. ″It's a win-

relationship. Many veterinarians need a simple dose change or a

win for everybody,″ he said. ″You're doing it for a good cause, and it

flavoring that they outsource.

helps your PR.″

There’s no switch fee, no DIR fee, any of these clawback fees.

That alone is worth it.

ELEMENTS | The business magazine for independent pharmacy | SEPTEMBER 2021

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MONEY

PLANNING FOR SUCCESS An attorney's guide to succession planning

Y

ou've put blood, sweat, and tears into your pharmacy business.

Many owners are hesitant to create a succession plan because it

You care about what you've built and the people you take

means confronting the most distressing possibilities. ″It does cover

care of. The last thing you want is for all your hard work and your

a number of scenarios and topics that maybe you don't really want

relationships to dissolve after you retire, leave your business, or

to talk about,″ Brehmer said. ″But going through the process now

worse, pass away.

when it's not a matter of concern is way more advantageous than

having to think about it once something happens.″

Succession planning ensures you leave your pharmacy in the

hands of someone you trust, preserves your future, and protects

your partners or family. Attorney Matthew D. Brehmer of Remley

they need to start thinking about succession, there is no better

Law, S.C., defines succession planning as ″putting together a plan

time than right now. ″The day you enter your business is the best

to make sure the transition of your business goes well in the future.

time to start planning for your eventual exit,″ Brehmer said. ″Not

It's a comprehensive road map to make sure you successfully exit

only does it put a plan in place in the event one of these scenarios

your business at some point.″

plays out, but it also helps maximize the value of your business.″

Although owners may think they have plenty of time before

This definition includes a diverse set of circumstances, even

though many business owners tend to define it narrowly. ″People

CREATING A SUCCESSION PLAN

often think it means, 'Well when I want to retire or sell my business,

A succession plan starts with your business's foundational

this is the plan I need to have in place for that process,'″ Brehmer

documents. These are articles of organization or articles of

said. ″While that is true, there are other instances that can occur in

incorporation that register your business with the state. They also

life that require succession planning, too.″

include an operating agreement or bylaws, depending on if you're

an LLC or a corporation. The documents cover governing rules for

The other instances are referred to as the five Ds: death,

disability, divorce, disagreement, and distress. ″These are all things

how your business is run, like whether you have annual meetings,

you likely do not choose or think will happen when they do. Getting

how decisions are made, how your business is wound up, how

that plan in place now helps you through that process.″

distributions are handled, how you are taxed, and more.

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″Those documents are really the foundation to your business,″ Brehmer said. ″It's important to have them in place because they

Going through the process now when it's not a matter of concern is way more advantageous than having to think about it once something happens.

are what really protects your personal assets from your business.″

Once the foundational documents are settled, you can start

to put together your buy-sell agreements, which outline what happens in the event one of the owners or partners wants to retire, wants to sell, passes away, or has a disagreement. You will likely need multiple agreements with specific instructions for different situations. ″How you handle those things might be the same across the board, or they might be different,″ Brehmer said.

The agreement might specify what happens in a 50/50

ownership if the two parties disagree. Is there a third party that you nominate ahead of time that would be the deciding factor? Do you go to mediation? Or arbitration?

It may outline what happens if one party decides to get out

of the business and sell their share for the interest. Do the other shareholders get first right of refusal to purchase it?

For all cases, the agreement specifies how to determine the

fair market value of the business. From there it would detail how to determine the value based on each scenario. For example, if there's a divorce among the shared owners, you might apply a discount, such as 20 percent off fair market value. The agreement would also specify how often to conduct the valuation—every year, every five years, or only once the succession occurs, for example.

″How the valuation occurs dramatically affects how much you

get and how much the company or your other partners have to pay,″ Brehmer said. ″If you plan ahead as to what you all agree on, that makes it much easier if someone wants to get out of the business.″

Once the value is decided, the agreement also determines

how the payment will occur, such as all at once or over time. Let's say the pharmacy owes money to a surviving spouse according to the agreement. It may not have enough to pay right away, so the agreement specifies the payment terms, such as a payment plan over 10 or 20 years.

Ultimately, you want every decision in place for every scenario

so that when it's time for succession, there's a clear plan to follow. ″If there's a disagreement between partners in the future and you don't have a plan, it's going to be really hard to figure out what you want to do with the company and how the company transitions or succeeds after you or with you,″ he said. ″If you make sure that all those terms are already agreed upon, you just follow what the agreements say.″

When developing these agreements, you should include not

only all the stakeholders but also several different professionals. ″It's more than just speaking with your business attorney or just your CPA or just your financial advisor,″ Brehmer said.

It's a comprehensive road map to make sure you successfully exit your business at some point.

ELEMENTS | The business magazine for independent pharmacy | SEPTEMBER 2021

19

″It is really important that all these people are involved in this conversation because you do need to consider all the different facets of succession planning.″ MOST COMMON MISTAKES In Brehmer's experience, not enough business owners make a succession plan. ″Every business owner enters their business out of passion and love,″ he said. ″But they don't have the proper plan for how the succession of their business is going to happen.″

Without a succession plan, you're subject to the default

rules per your state's statutes. That means the transfer of your business will land in the hands of the court, and your default beneficiaries will have to endure a six- to nine-month probate before your assets are transferred.

If you don't designate a beneficiary, things get complicated

for different family situations. If you have children from a prior marriage, for example, half of the business would go to your spouse and half to those children.

″It can get very messy, and obviously having a probate

handle your business during that transition is very complicated with accounting and court filings,″ Brehmer said.

Another mistake is using boilerplate agreements, whether

it's the operating agreement, the bylaws, or the buy-sell agreement, often simply printed from the internet. ″That's likely better than nothing, but it doesn't take into account the individual circumstances that affect your business every day, so it's important to make sure you go through the actual process and have a well-developed plan with your advisors.″

The most common mistake is waiting too long. ″You need

to start thinking about how you're going to maximize the value, so when you sell, you are in a position to sell,″ he said. ″There's a very big difference between what we say is 'owner readiness' and 'business readiness.' Sometimes the owner is ready to exit their business, but their business isn't ready for it. If you maximize value through a succession plan, why would you not want to do that from day one?″

The day you enter your business is the best time to start planning for your eventual exit.

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THE 5 Ds

Ds

A succession plan will cover your business in the case of one of the five Ds. Death Disability Divorce Disagreement Distress

THREE LEGS OF THE STOOL Answer and align these three questions to create a succession plan ″that sets you and your business up for success after you sell your business,″ says attorney Matthew D. Brehmer, a certified exit planning advisor through the Exit Planning Institute, which teaches these ″three legs of the stool″ as a standard approach in exit strategy.

Business How do you maximize the value of this business?

Financial What do you need financially from the business to support yourself in the next chapter of your life?

Personal What does the next chapter of your life look like?

ELEMENTS | The business magazine for independent pharmacy | SEPTEMBER 2021

21

FEATURE

MAKING THE TRANSITION Transitions of care is a win-win for pharmacies and hospitals

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W

hen a patient moves from an inpatient facility like a hospital to an outpatient or community setting, a ″transition of care″

occurs. During this time, pharmacists have the opportunity to step

The access to EMR is a massive help, Shannon says, because it closes an information gap between the hospital and pharmacy.

The pharmacy knows exactly what prescriptions should have

in and make a big difference in health outcomes—and profit for

been prescribed as well as any medications that may have

their pharmacy.

been discontinued.

The reason lies in the problem of hospital readmission rates.

When a patient gets readmitted to the hospital within 30 days

Then, they sit down with the patients to do a medication

reconciliation. They go over medication history, how patients are

of discharge, it's an indication that something might have gone

taking them, and how they are tolerating them. The pharmacy

wrong in their transition back home. That leads to a worse health

collaborates with the hospital physicians to make any necessary

outcome for them, plus more healthcare costs for the insurer.

changes. After the initial appointment, they follow up with the

patients on day three after discharge, day seven, day fourteen, and

To discourage unplanned hospital readmissions, the

Affordable Care Act of 2012 introduced the Hospital Readmissions

then monthly thereafter.

Reduction Program, which penalizes hospitals for unplanned

readmissions by reducing Medicare reimbursements—creating a

coordinate their follow-up appointments. ″So often I'll ask, 'When's

pain point for hospitals and an opportunity for pharmacies.

your cardiology appointment?' and they don't have one scheduled,″

To help hospitals keep their readmission rates down,

Lily's also goes the extra mile for patients by helping them

Shannon said.

pharmacies can step in to provide patient care and counseling

that will prevent unnecessary readmissions. ″These transitions are

to the emergency room because they've run out of medication.

The pharmacy also steps in to prevent patients from going

really crucial to patients' recovery and ability to maintain health

If a patient has 30 days of meds but their appointment isn't for

without inpatient care,″ said Carlie Traylor, director of strategic

another 38 days, the pharmacy will call the inpatient doctor to see

initiatives and student affairs at NCPA. ″Ultimately, medication

if they can extend the prescription so they don't run out before

reconciliation will be the main star and why the pharmacy is part of

their follow-up. ″These simple five-minute phone calls from the

this conversation.″

pharmacist can really save a life,″ Shannon said.

Richard Logan and Tripp Logan, owners of L & S Pharmacy

WHAT IS TRANSITIONS OF CARE?

in Charleston, Missouri, first introduced their transitions of care

The counseling and services entailed in a transitions of care

program around 10 years ago. The transition from hospital to

program will vary based on each pharmacy's business, but most

home is the first step in a longitudinal care program that helps

programs include a medication reconciliation session immediately

patients maintain their health long after their discharge.

after the patient is discharged as well as regular check-in sessions

for at least a month.

optimization services and counseling sessions with a pharmacist,

but the intervention doesn't end there. After receiving an initial

Coming from an ambulatory care background, pharmacist and

When they leave the hospital, patients can receive medication

owner of Lily's Pharmacy Jennifer Shannon always knew she would

consult, a patient may be enrolled in a care coordination program.

provide transitions of care services when she opened her own

This includes chronic care management services, in which the

practice in Johns Creek, Georgia. When patients are discharged

pharmacy coordinates with primary care providers to help patients

from the local hospital, they have the choice to opt into Lily's

set monthly goals related to their health. They also have condition-

transitions of care program.

specific programs like blood pressure training to help patients

″We have remote capabilities during their inpatient stay, so as

better understand their condition.

soon as they opt in, I can log into the EMR system for the hospital and

monitor changes throughout their stay,″ Shannon said. ″Then, when

hospital in the next five years, not just in the next 30 days,″

they are discharged, the pharmacy already knows the full picture.″

Tripp Logan explained.

″Really these services ensure patients don't go to the

You have to look at total care and what it means for your community. That’s part and parcel of what we’re doing.

ELEMENTS | The business magazine for independent pharmacy | SEPTEMBER 2021

23

When L & S first started providing transitions of care services, they entered into a pilot program with their local hospital. It was no cost to the hospital at the beginning, but they've moved on to a fee-for-

WHAT IS THE HOSPITAL READMISSIONS REDUCTION PROGRAM? The Hospital Readmissions Reduction Program is a provision of the Affordable Care Act of 2012 that requires the Centers for Medicare & Medicaid Services to penalize hospitals that have excess readmissions within 30 days.

It links reimbursements to readmissions—when a hospital has an unplanned readmission, they have to pay a penalty. The intent of the program is to incentivize better communication and care coordination after patients are discharged from the hospital.

The HRRP includes six specific conditions and procedures as part of its 30-day risk-standardized unplanned readmission measures, which include:

service model where they bill providers each time they perform a service that is covered under their contracts.

At Lily's Pharmacy, most of their transitions of care patients

are enrolled in the pharmacy's medication packaging program, which nets a tidy $30 per patient per month. The main benefit of transitions of care hasn't come from prescription revenue, but the individual contracts with providers.

″We've seen a 300 percent return on investment with our

transitions of care program,″ Shannon said, mostly attributed to the program's slow but steady expansion into more facilities throughout the area. ″It started on two floors of the hospital, then it went into the whole hospital. Then it expanded out to the rehab facility and to smaller practices in the area. And now we're doing transitions of care for basically all the fire departments and EMS in our area.″

Though getting a foot in the door was a challenge, Lily's

transitions of care program has proved its value to providers, which allowed it to grow into a profitable powerhouse.

• Acute myocardial infarction • Chronic obstructive pulmonary disease • Heart failure • Pneumonia • Coronary bypass graft surgery • Elective primary total hip arthroplasty and/or total knee arthroplasty More conditions and procedures may be added in the future.

We’ve seen a 300 percent return on investment with our transitions of care program.

The HRRP creates space for pharmacies to offer muchneeded transitions of care services. By involving pharmacies, discharged patients will get more attentive care that leads to better health outcomes, and in turn, hospitals will get a higher reimbursement.

ESTABLISHING A PROVIDER RELATIONSHIP One of the most difficult challenges of providing transitions of care services is breaking into the market—making those first A PROFITABLE PARTNERSHIP

connections with hospitals in your area and convincing them your

A transitions of care program isn't only good for the hospital's

services will actually save them money.

bottom line—it's good for the pharmacy's bottom line, too. ″There

are opportunities to get paid for it, specifically through Medicare,″

to provide transition services that would help reduce readmission

When Lily's Pharmacy first opened, Shannon's primary goal was

Traylor explained. ″And Medicare sets the tone for insurance coding,

rates, but establishing that first relationship took a lot of legwork.

so a lot of private insurance companies follow suit.″

every week saying, 'Hi, I run Lily's Pharmacy and I would love to

Beyond Medicare reimbursement, the individual contracts with

″Nobody knew who we were. I was literally calling the hospital

hospitals and other providers can prove lucrative. ″Hospitals are

collaborate with you. Call me back.' And nobody would call me back.″

highly motivated to get their overall scores up,″ Traylor said, which

means they will pay out in their contracts with pharmacies.

her case to the hospital's director of pharmacy about how a

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After finally getting a real person on the line, Shannon made

transitions of care partnership had the potential to improve patient outcomes and save the hospital money. They were sold. The hospital even canceled a meds-to-beds program they'd had with a large chain pharmacy in favor of Shannon's proposal.

What these services do is ensure that patients don’t go to the hospital in the next five years, not just in those 30 days.

From that meeting, it took some time to get things up and

running. They had to wait on the lawyers to get the legal language just right and also become a preferred provider.

Richard Logan persuaded hospitals by using data about

readmissions that most of the hospitals were completely unaware of. ″The majority of hospital readmissions and the penalties they were suffering were because of medication mismanagement,″ said Richard Logan. ″So we took that information to the hospital.″

In a brief meeting with local healthcare entities, he presented

TRANSITIONS TOOLS Not sure how to start in building your transitions of care program? Check out these resources to set your program up for success.

NCPA The National Community Pharmacists Association has developed a toolkit that includes: • Information about the disease states affected by the Hospital Readmission Reduction Program • Mock service agreements, financial documents, and business plans • Success stories

PHARMACY SOCIETY OF WISCONSIN The Pharmacy Society of Wisconsin breaks down transitions of care into five domains in their toolkit: • Discharge medication reconciliation • Discharge patient education • Discharge prescription management • Pharmacy hand-off communication • Follow-up communication

CENTERS FOR MEDICARE & MEDICAID SERVICES Visit CMS to learn about the Transitional Care Management billing codes you can use for Medicare patients with conditions of moderate medical complexity or high medical complexity.

a PowerPoint highlighting readmission stats and his proposed solutions. ″At the end of the little five-minute presentation, there was silence. I thought, 'Did someone bring a skunk into the room?' But then they were saying, 'Why haven't we been doing this all along?'″

One key to their argument was reminding hospitals that there

was more to pharmacy services than someone counting pills behind the counter. The pharmacy could share the burden with the hospital so they could work less, get paid more, and have healthier patients.

Although the Logans presented solutions to the hospitals, more

importantly they listened. ″We asked the questions, 'What do you need from us? What are you struggling with and what could be helpful?'″ Tripp Logan said. ″We didn't go in and tell them what we were going to do for them. We went in and asked what we could do.″

To make these crucial connections, pharmacists will have to

step away from the counter. You may cringe thinking about the lost work time, but Tripp Logan encourages pharmacists to think of this time away from the counter in terms of marketing. ″For a pharmacist to step out for an hour-long meeting, that's $65 or $100,″ he said. ″If you consider that against Facebook ads, television, or whatever marketing opportunities pharmacies use, that time spent away is similar to a typical marketing budget.″

Getting out in your community will help you attract patients

who need complex care, which is worth more in the long run than winning over patients with one or two low-cost prescriptions. ″It's a pivot we've had to make in the last 10 years to attract the right partners and the right patients, just in a different way than your typical marketing efforts,″ said Tripp Logan.

Traylor recommends not limiting your search for a partner

to hospitals but to include local healthcare practices and nursing homes, too. The bigger the organization you partner with, the more it will disrupt your workflow. If you aren't ready for a large influx of prescriptions and counseling sessions, starting with a smaller provider may be a wise choice.

ELEMENTS | The business magazine for independent pharmacy | SEPTEMBER 2021

25

CONNECTING WITH PATIENTS Beyond the contracts with providers, a transitions of care program

can constantly remind each other, 'This person is leaving tomorrow,

can introduce you to new patients—and win them over for the long

do they have everything they need?'″

term. The care that patients get when they transition from hospital

to home can lead to a light bulb moment when they realize the

of adaptation and communication. ″Especially during Covid, we

depth and breadth of services independent pharmacies provide. ″It's not an auto-fill program. You're reviewing patients' medications

To keep everyone on the same page, there's a constant cycle

frequently met so the whole team knew what was going on,″ Shannon said.

each month and preventing problems before they interfere

with the patient's life or care plan. And you're helping them live

team since introducing transitions of care and chronic care

L & S Pharmacy has seen a gradual growth of their pharmacy

a healthier life with minimal medications,″ said Traylor. ″That

management services over the past decade.

absolutely helps win over new patients.″

Tripp Logan said. ″We've been able to bring on people to support

Because Lily's Pharmacy started working in transitions of

care right when they opened their doors, they didn't have a large

″Our team has evolved, but it's evolved based on funding,″

these initiatives, but it was never unmanageable because we

base of existing patients on the retail side. Shannon estimates

weren't overwhelmed with a thousand new patients all at one time.

that the majority of their current patients initially connected to the

It's a slow relationship.″

pharmacy because of their transitions of care services.

of the growing program while others have had their roles and

Typically, transitions of care patients will switch over their existing

prescriptions to Lily's after going through the transition program.

″For the most part, they become long-term patients,″ Shannon

Over the years, people have been hired to meet the needs

duties shifted, but none of these changes happened on day one of the program.

said. ″They realize it's not just the transition of care, but the level of care they get all the time.″

Although L & S Pharmacy does connect with new patients

through referrals for their transitions of care services, the sweet spot is getting more from their current patients. They already use the pharmacy to fill their prescriptions but then become eligible for transitions of care services after a hospital stay or are recommended for chronic care management by their physician.

″That's the easiest one to organize because the relationships

are already there,″ said Tripp Logan. ″And that's essentially what partners are paying us to do—to support the patients that already frequent our pharmacies with the things they need help with.″ MANAGING WORKFLOW When you introduce transitions of care services, expect slow but steady changes to your pharmacy workflow.

Before you even start offering the service, Traylor

recommends shifting from a ″reactive″ to a ″proactive″ workflow to help you prepare for increased volume. ″That means the pharmacy isn't just waiting for a patient to come in and refill their medications,″ she explained. ″They are using clinical med sync to make sure patients have all their refills lined up.″

After a pharmacy has a significant portion of prescriptions being

filled proactively through medication synchronization—around 40 to 50 percent, Traylor recommends—adding transitions of care services will be seamless, because the system is already in place.

″Once you hit critical mass with your med sync programming,

you'll be able to retool people's positions,″ said Traylor. ″I would definitely say you need a strong technician who has good rapport with patients.″

At Lily's Pharmacy, transitions of care services are a team

effort. As a top priority, every technician and pharmacist is trained to do their part. ″I like everyone to know how to do everything in our pharmacy. The whole team gets involved,″ Shannon said. ″We

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ACCELERATE WORKFLOW WITH PHARMACY STUDENTS As you build your transitions of care program, you may find you need an extra set of hands or two to help with the increased workload. One low-cost way to do that is to reach out to local pharmacy schools to connect with pharmacy students.

Depending on the pharmacy school, you can bring students into your pharmacy for a very low cost, no cost, or even get paid by the school to take these students on. ″Pharmacy students can do everything a tech can do and then some,″ Carlie Traylor from NCPA said. ″They are training to be a pharmacist, and they have lots of clinical knowledge.″ Sarah Oprinovich, a program manager for Balls Food pharmacies, uses pharmacy students to assist with the transitions of care program at their pharmacies.

She says there's a lot of work involved in getting pharmacy students up and running in the pharmacy, but it's ultimately a low-cost way to get more hands on deck. ″We have to observe them for the first three months, and then after that we're reviewing their documentation,″ she said. ″They also turn over pretty much every year, so you have to prepare long-term patients for that and figure in the period of training every year.″ Traylor added, ″I recommend building relationships with enough schools that you can ask for students during every rotation.″

TRANSITIONS OF CARE FOR SELF-INSURED COMPANIES

Ultimately, medication reconciliation is going to be the main star and why the pharmacy is part of this conversation.

Most pharmacies that provide transitions of care services will turn to a hospital or private practice for a partnership.

But that's not the only way to make an impact.

Sarah Oprinovich is the program manager for a series

of pharmacies located inside Balls Food stores, a grocery chain in the Kansas City metro area. The stores are selfinsured, and transitions of care services are provided to employees by the pharmacy to keep the company's healthcare costs down.

″We get notification from insurance or our third-party

administrator that one of our employees has been in the hospital and we get their diagnosis,″ Oprinovich explained. ″Then the pharmacist will reach out and do medication reconciliation and counseling.″

The program is open to almost every kind of hospital

discharge, from motorcycle accidents to diverticulitis. The only LESSONS LEARNED

conditions they don't tackle through transitions of care are

Over the years, Lily's Pharmacy and L & S Pharmacy have adjusted

substance use disorder and patients entering long-term care.

their programs so things run more smoothly.

receive their medication reconciliation and counseling, but

One thing Shannon says she would do differently is forego home

For most patients, the intervention ends after they

visits. ″I was so eager to get the full picture, but every time you go

patients with conditions like diabetes or cardiovascular

into a house, you don't know what you're going to walk into.″ Not

problems will be enrolled in the pharmacy's disease-state

to mention, the home visits demanded a lot of time away from the

management program for more thorough follow-up.

pharmacy. Keeping the service inside the pharmacy means the staff

can focus on care in a neutral environment, plus they have the benefit

intent is ultimately to reduce hospital readmissions, but

Like a traditional transitions of care program, the

of the rest of the pharmacy team being there to help if needed.

it's the self-insured employer that reaps the benefit of the

associated cost savings rather than the hospital.

L & S was sure their services could make a difference in their

community, but Tripp Logan says their mistake was thinking they

had all the answers. ″We assumed we had the answer only to find

individual hospitals, the pharmacy can give transitions of

Since they don't base services on contracts with

out there were 500 different possible answers and we only had one

care services to any patient, regardless of their hospital.

of them.″

However, Oprinovich has faced some challenges with

He advises pharmacies to look around at other independent

waiting on insurance to get the pharmacy the information

pharmacies and learn from their mistakes instead of making the

they need to initiate services.

mistakes firsthand. He said, ″We're very involved with CPESN right

now, which means we don't have to reinvent the wheel every time.

want to provide discharge counseling within the first couple

of days after discharge, but sometimes we wouldn't even

A lot of times colleagues have learned those lessons for us, and

in turn we've tried to share what we've learned and best practices

″There's often a delay,″ she explained. ″Normally you'd

get notified for over a week, depending on how long it took

with others so it's not as expensive for them to start these programs.″

the hospital to send the bill and how long it takes for a

report to be generated and so on.″

By getting outside of the bubble of your own pharmacy and

talking to the in-patient facilities in your area, you can design a

better program. ″You have to look at total care and what it means

Oprinovich says that working with local health systems to

for your community. That's part and parcel of what we're doing,″

coordinate care has been relatively simple, even without a

said Richard Logan. ″It's community care.″

formal transitions of care agreement in place.

However, once they actually receive notification,

For companies that are self-insured and shouldering

high costs when their employees are hospitalized, the idea of reducing readmissions can be very appealing. And for pharmacies that may not be ready to commit to taking on the prescription and counseling volume that comes with working with a hospital, proposing transition services to businesses in the area could be a way to break into transitions of care with minimal disruption to existing workflow.

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ELEMENTS | The business magazine for independent pharmacy | SEPTEMBER 2021

29

PILLS TO PRISON Millions are incarcerated—and they need meds

M

from the Pew C eport har ”ar itab ns, o le s Tr ri P us e t ts ta

Source: “Pha rma ceu tic als in

S

OUTLOOK

HIGHEST COST CONDITIONS IN STAT PRISONS BY TOTAL EXPENDITURE 1. HIV 2. Hepatitis C 3. Diabetes 4. Hemophilia

ore than two million people are currently incarcerated in the

5. Oncology

United States—and many of these inmates have complex

medical needs. In 1976, the Supreme Court ruled in Estelle v.

Gamble that prisoners have a constitutional right to adequate medical care, and Departments of Corrections are required to treat illnesses of people in custody. That means millions of inmates need a pharmacy to provide medications that the government will pay for.

RxCare, a long-term care pharmacy, sister company of Carolina

Apothecary in Reidsville, North Carolina, has found that serving their county's local jail and nearby youth detention centers is a profitable niche that increases prescription volume and presents very few challenges. And it is revenue that isn't touched by thirdparty insurers or PBMs.

″We've found that detention centers are very easy to service,″

said Ed Leake, pharmacist manager at RxCare. ″It's prompt income since you're not billing an insurance company, you're billing the facility directly, and it's a consistent volume.″

Having operated as an independent retail pharmacy since 1945, Carolina Apothecary formed RxCare in 2003—a closed-door longterm care pharmacy. At first, they served traditional long-term care facilities like assisted living and group homes, but around five years ago they were introduced to the idea of servicing jails after securing a contract with a company that served youth detention centers.

″Working with the youth detention centers is what led us to

go to our local county jail and say, 'We'd like to make a proposal for pharmacy services,″ Leake said. So RxCare put together a proposal, had it accepted, and has been serving their local inmate population ever since.

Working with both the youth detention centers and their county

jail was an easy extension of RxCare's existing long-term care services with the perk of dealing with a lot less red tape. ″When you serve an assisted living facility, there's a lot of regulations, insurance companies, PBMs, and medical professionals you work with,″ Leake

JAIL AND PRISON: WHAT’S THE DIFFERENCE? The words ″jail″ and ″prison″ are often used interchangeably, but they serve different purposes and populations. Before you start offering prison pharmacy, get to know the difference.

Federal Prison: Individuals are sent to federal prison when they are convicted of a federal crime like tax evasion, a crime on federal property, or a crime in which they crossed state lines. Federal prison stays tend to be longer than state prison sentences. There are 226,000 people currently in federal prison.

State Prison: Individuals who violate state laws rather than federal laws go to state prison. These prisons tend to have more violent offenders, but shorter sentences.

There are 1.2 million people currently in state prison.

Local Jails: Local jails typically hold people who have been sentenced to a short term, people still making court appearances, and people awaiting sentencing.

There are 631,000 people in local jails, and 470,000 of them have not yet been convicted of a crime.

30

Source: “Mass Incarceration: The Whole Pie 2020,” PrisonPolicy.org pbahealth.com/elements

said. ″A lot of nurses, doctors, state inspectors, insurance auditors, and others.″ However, in the detention center, all the healthcare decisions are made in-house. All the pharmacy has to do is fill the prescriptions and deliver them in a timely manner.

SECURING THE CONTRACT When RxCare put together a proposal for their county jail five years ago, Leake looked at how other pharmacies were working with nearby counties. ″RxCare's goal was to negotiate a contract that would give the county the lowest price possible with exceptional customer service,″ Leake said. ″That's what we were able to do and the contract was accepted.″

Keeping costs low is a big priority for prisons and jails.

According to research done by the Pew Charitable Trusts, $8.1 billion was spent on healthcare costs for inmates in 49 states in 2015, and state Departments of Corrections reported that the cost of pharmaceuticals was one of their top concerns. Other top concerns were tied up with the overall cost of drugs, like the aging prison population and the increase in disease severity among inmates of all ages.

The proposal RxCare made to their county jail provided a clear

explanation of what the county would pay for medication and supplies. And it worked well for the pharmacy because they knew

what they were going to get paid. ″It's based on real-time pricing,″ Leake said. The pharmacy doesn't have to rely on the formulary's out-of-date pricing that is usually months old. ″As we purchase inventory from the wholesaler, the price is generally updated every three or four days. So the jail is constantly getting the lowest price possible because we're always going to buy the lowest priced medications. That's a tremendous asset for the county.″

Leake said that RxCare fills thousands of prescriptions

for the jail every month. When the pharmacy gets an order for prescriptions, his priority is to look for the lowest price available.

He uses his pharmacy management system to find that information, so it doesn't take very long.

Occasionally, when the pharmacy gets a prescription for a drug

that is very expensive, they will contact the jail's prescriber and see if they can change it to a less expensive option. ″It's always the lowest price,″ Leake said.

LOGISTICS & CHALLENGES For a pharmacy that already does a high volume of long-term care prescriptions, adding prescriptions from correctional centers doesn't change much about the daily workflow.

″We've been doing long-term care for decades, and this is

a natural extension,″ Leake said. ″The prescriptions are packed in specialized packaging and all orders are delivered within the same day. It's a quick process to turn around with the correct systems in place.″

Compared to working with assisted living facilities and nursing

homes, the county jail has significantly fewer challenges to deal with. The main rule for the county jail that RxCare serves is that the medicine has to be delivered in a secured tote and signed for.

PRISON HEALTHCARE DELIVERY Federal, state, and local prisons and jails all tackle healthcare and pharmaceutical acquisitions differently. Here's a primer.

Federal Prison Healthcare System The U.S. Federal Bureau of Prisons has a pharmacy program that includes both civilian pharmacists and pharmacists from the U.S. Public Health Service Commissioned Corps. The bureau has a biennial residential training conference to credential pharmacists.

Source: Pharmacy Today, Vol. 25, Iss. 2, p34-35, https://doi.org/10.1016 jptdy.2019.01.016

State Prison Healthcare Systems Across the United States, there are four different healthcare delivery systems. This dictates how they purchase pharmaceuticals.

Direct-provision model: In 17 states, the Department of Corrections employs healthcare professionals who provide care Contracted provision model: In 20 states, healthcare is delivered by a private provider State university model: In four states, healthcare is provided by the staff from a public university Hybrid model: In eight states, healthcare is provided through a combination of the above three models.

Source: “Pharmaceuticals in State Prisons,” a report from the Pew Charitable Trusts

It’s prompt income since you’re not billing an insurance company, and it’s a consistent volume.

Local Jail Healthcare Systems How care is delivered in county and city detention centers varies widely from location to location.

In some states, local institutions fall under the jurisdiction of the state-level Department of Corrections. In others, the local institutions make their own healthcare arrangements.

ELEMENTS | The business magazine for independent pharmacy | SEPTEMBER 2021

31

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The challenge of serving this particular population of patients is keeping track of everyone and their medications. Prisoners are transferred around from county to county pretty regularly, often because they need to appear in court in another part of the state, but their medications aren't allowed to go with them. Leake said, ″We have to obtain this information from other counties and getting those records can take a while.″

FACTS AND FIGURES • 4 3.8% of state inmates have a current medical problem • 10.3% have 2 current medical problems • 7 .5% have 3 or more current medical problems • 3 6.2% will be injured while incarcerated, either in an accident or a fight • 12.3% will have surgery while incarcerated

The jail is constantly getting the lowest price possible.

That’s a tremendous asset for the county.

TOP CONDITIONS FOR STATE INMATES • Arthritis

• Asthma

• Hypertension

• Hepatitis

• Tuberculosis

• Diabetes

PRE-EXISTING PROBLEMS State inmates are also likely to come into the system under circumstances that can have lasting effects on their health, including: • Having experienced homelessness • History of intravenous drug use • History of alcohol dependence • Existing dependence on alcohol or drugs Source: “Medical Problems of Prisoners,” U.S. Department of Justice, Bureau of Justice Statistics

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