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ELEMENTS MEDICAL MARIJUANA A look at pharmacists’ roles in this emerging industry
CHIP IN Is your pharmacy prepared for the switch to chip cards?
Pharmacy Expansion The how-to’s, challenges and benefits of opening additional pharmacy locations
VOL. 4 ISS. 3 | SEPT 2015 | PBAHEALTH.COM/ELEMENTS
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ELEMENTS
The business magazine for independent pharmacy
STAFF & CONTACTS Matthew Shamet – Publisher and Editorial Director Kirsten Hudson – Editor Kellie Paxton – Art Director Kathleen Barbosa – Contributing Writer Jennifer Salva – Contributing Writer Chloe Holt – Contributing Writer Paige Fisher – Graphic Designer INTERESTED IN ADVERTISING? elements@pbahealth.com
Contents Departments 20 SPOTLIGHT:
5 NEWS:
Track-and-Trace Understanding the requirements of the Drug Supply Chain Security Act. 6 TRENDS:
Medical Marijuana A look at pharmacists’ roles in this emerging industry. 8 RETAIL:
Sports Nutrition How Everett Pharmacy is using sports nutrition to draw in new patients. 11 SOLUTIONS:
At Your Disposal How to safely dispose of sharps in your pharmacy.
ON THE WEB //
Diabetic Sales Offering supplementary products for patients with diabetes can boost revenue. 24 MONEY:
Chip In Is your pharmacy prepared for the switch to chip cards? 30 OUTLOOK:
Pharmacy Accessibility Creating an inclusive pharmacy for individuals of all ability levels. 34 NOTES:
Flavor of Engagement Improve patient loyalty and trust with a personalized service.
Feature: Pharmacy Expansion
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The how-to’s, challenges and benefits of opening additional pharmacy locations.
Find more strategies, tips and expert advice to improve your business at pbahealth.com/elements.
5 Time-Saving Technologies for Your Pharmacy
Time is your most valuable resource. Consider investing in new technologies to save time in your pharmacy. Read more at pbahealth.com/5-time-saving-technologies-for-your-pharmacy.
ELEMENTS is published quarterly by PBA Health. Copyright© 2015 PBA Health. All rights reserved. Neither this publication nor any part of it may be reproduced without written permission by PBA Health.
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NEWS
Trackand-Trace Understanding the requirements of the Drug Supply Chain Security Act Pharmacies have a central role to play in the Drug Supply Chain Security Act (DSCSA), the latest industry effort to track prescription drugs through the supply chain. The DSCSA is the track-andtrace portion of the Drug Quality and Security Act (DQSA), which was signed into law in November 2013. The track and trace requirements of the DQSA are meant to improve drug security throughout the supply chain, including making it easier to track where a drug has been, to identify and remove counterfeit products, and to simplify drug recalls. All members of the supply chain—manufacturers, repackagers, wholesale distributors, third-party logistics providers and dispensers, including retail pharmacies—will have to comply with the law as it’s phased in over the next nine years. WHAT YOU ALREADY NEED TO BE DOING: Verifying your trading partners Effective date: Jan. 1, 2015 Your pharmacy is required to verify that all of your trading partners have a valid license, and are registered per federal and state law. Develop and implement protocols to verify all new trading partners
What are the “3Ts”? 1. Transaction information
2. Transaction history
This information, which can be provided in paper or electronic format, includes the name of the product, strength and dosage form, NDC, container size, number of containers, transaction date, shipment date, name and address of the seller and buyer, and lot number, if applicable.
This is a paper or electronic statement that includes the transaction information for each prior transaction of the product back to the manufacturer.
and be sure to regularly audit your current trading partners. Identifying suspect and illegitimate product Effective date: July 1, 2015 Pharmacies need protocols to identify suspect and illegitimate products. These procedures should help you: • Identify suspect product currently in inventory and among new products • Inform trading partners about suspect product • Quarantine suspect product from regular inventory • Remove illegitimate product from the supply chain • Notify the Food and Drug Administration (FDA) and all trading partners within 24 hours after determining that a product is illegitimate
3. Transaction statement This is a paper or electronic attestation transferring ownership of the product.
Although the product tracing obligations under the DSCSA went into effect July 1, 2015, the FDA won’t enforce them for pharmacies until Nov. 1, 2015. In the meantime, pharmacies need to work toward complying with the requirements, which means only accepting product if the previous owner provides the “3Ts” (transaction information, transaction history and a transaction statement), and capturing and maintaining the “3Ts” for six years from the date of the transaction. If your pharmacy sells or loans product, you’re currently required to provide the “3Ts” to the subsequent owner, unless the subsequent owner is a patient. The deadline was not extended for this requirement.
Follow Elements magazine on Facebook and Twitter for pharmacy business tips and advice, news announcements, industry
WHAT YOU’LL NEED TO DO SOON:
information and exclusive offers.
Accepting, maintaining and providing transaction data Effective date: July 1, 2015, but it won’t be enforced until Nov. 1, 2015
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TRENDS
Medical Marijuana A look at pharmacists’ roles in this emerging industry With more and more states legalizing marijuana for both medical and recreational use, medical marijuana is a business opportunity pharmacists can start looking into. “Pharmacists are the ideal professionals to dispense medical marijuana, or to at least have knowledge about it,” said Joseph Friedman, R.Ph., MBA, while presenting a continuing education session, “Medical Marijuana and the Pharmacist Behind the Curtain,” during the Connect 2015 PBA Health Conference & Business Seminar in July. “After all, we are the drug experts.” Friedman is in the process of opening his own medical marijuana dispensary in Illinois. In September 2014, he was awarded one of 57 licenses to own and operate a medical marijuana dispensary in Illinois, and he hopes to open his dispensary later this year. Currently, 24 states and the District of Columbia have legalized medical marijuana. Forbes estimates that 2.4 million people in the U.S. have registered as medical marijuana patients, and projects that the industry will
By the numbers Number of states that have legalized marijuana for recreational use (Alaska, Colorado, Oregon and Washington) Number of states that have legalized marijuana for medical purposes Number of states that have pending legislation regarding medical marijuana
Sources: CNN; “Medical Marijuana and the Pharmacist Behind the Curtain,” A continuing education session by Joseph Friedman, R.Ph., MBA
grow to $9 billion by 2017. Friedman said he expects more states to legalize medical marijuana in the next five years, and that pharmacists are in an ideal position to join this growing industry. “There’s a whole wealth of possible benefits based on doing this right—dosing it right, giving it to the patient right, and counseling the patient correctly,” he said.
TRENDS
WHY PHARMACISTS? “Medical marijuana is a real drug with real side effects,” Friedman said. “It deserves the same close attention that every other legitimate drug requires.” For example, patients can experience an increase in heart rate and a decrease in blood pressure after initially consuming marijuana. “New patients should be made aware of this,” he said. “This is exactly the kind of information licensed pharmacists are trained and experienced to provide.” And patients will look to you for that knowledge— whether or not you own a dispensary. “When these patients are going to the dispensary down the street, it’s important that you have an idea of what they’re taking and that you can counsel them,” he said. Friedman also said pharmacists have the skills, training, experience and education to help patients manage marijuana use. And, pharmacists have that allimportant patient-focused mindset. “We know what questions to ask. We know how to monitor patients, and we also know how to interact with other health care professionals,” he said. In addition to the clinical skills, Friedman said pharmacists also already have the operational skills needed to manage dispensing medical marijuana, such as dealing with difficult suppliers, maintaining quality inventory controls and complying with strict rules and regulations. LEGAL ISSUES While pharmacists may be the ideal health care professionals to dispense marijuana, Friedman said there’s one huge obstacle: Marijuana is illegal. “Cannabis is a Schedule I drug, according to the Controlled Substances Act,” Friedman said. “This means that in the states and the District of Columbia that have legalized medical marijuana, all licensed and registered medical marijuana growers, distributors and patients are breaking federal laws under the Controlled Substances Act every single day.” “Even though medical marijuana may be legal where
you live and work, the federal laws are having a huge impact on the business,” he said. “Because of warnings from the U.S. Justice Department, banks are reluctant to open bank accounts—or loan money—to legal medical marijuana businesses. As a result, medical marijuana is a cash-only business. Just imagine how dangerous that is.” Friedman called for cannabis to be federally reclassified and for more legal clarification and guidance on the industry. “Each jurisdiction has different rules and regulations,” he said. “There’s no standardization. None. It’s like the Wild West.” THE FUTURE Many aspects of dispensing medical marijuana are still unclear, but the push for pharmacists to take part is happening. Colleges of pharmacy are creating courses and sponsoring lectures on medical marijuana, Friedman said, and national organizations are preparing. “The National Association of Specialty Pharmacy (NASP) developed a task force on medical marijuana about a year and a half ago because they felt that all of those patients who walked into specialty pharmacies were also the types of patients who would be getting medical marijuana,” Friedman said. “At the end of last year, NASP established the National Association of Cannabis Based Medicine (NACBM) to help pharmacists obtain the required coaching to make the most of cannabis as a therapy, particularly within the retail channel,” he said. As well, the Cannabis Training Institute, an online training and certification resource for cannabis businesses, entrepreneurs, clinicians and policymakers, is currently preparing certification for pharmacists. “I’m working alongside other pharmacy content experts to develop pharmacist CE modules that will be ACPE-accredited,” Friedman said. “These modules will begin to be available this fall.” For more information, visit the National Association of Cannabis Based Medicine at nacprx.site-ym.com and the Cannabis Training Institute at cannabistraininginstitute.com.
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RETAIL
Sports Nutrition How Everett Pharmacy is using sports nutrition to draw in new patients Niche products and services are more important than ever in pharmacies today. But it can be hard to know what’s right for your independent community pharmacy. “One of the biggest things with independent pharmacy is trying to find your niche—what sets you apart from the others,” said Tyler Ruby, Pharm.D., staff pharmacist at Everett Pharmacy in Everett, Pa. “As a smaller independent pharmacy, you have to think outside the box.” An open mind and personal interest led Ruby, along with Everett Pharmacy owners Karen Iseminger, R.Ph., and Dan Iseminger, R.Ph., to consider how sports nutrition could work in—and for—their business. They recently added a sports nutrition section to the front end that includes protein powder, mass gainers, electrolyte drinks, amino acids, carbohydrate gels and protein bars. “The owners and I are all very athletic,” Ruby said. “I’m always buying supplements, and we saw these products as a great way to bring our own interest into the pharmacy, while drawing in a new, younger set of patients at the same time.” “If we can get some younger people in here to look at these products, then as they start aging, or even just get a cold, they’ll think of coming to us to get their prescriptions filled,” Ruby said. SPREAD THE WORD One of the most important areas to consider when establishing a sports nutrition section in your pharmacy is marketing. “You need to get the word out there and
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By the Numbers $2.6 billion Sales of sports nutrition products in 2014
37 Percent of adults who purchase sports nutrition products
18-44 Core age group of adults who purchase sports nutrition products
50 Percent that reflects how much more likely men are to be heavy buyers of sports nutrition products than women
2 Hispanics are twice as likely to be heavy buyers of sports nutrition products than non-Hispanics Source: Eighth Annual Vitamin and Sports Nutrition Study, TABS Group
grab people’s attention,” Ruby said. Ruby recommends passing out flyers at local gyms and advertising at local athletic events, like 5K races. “An independent pharmacy isn’t where young people think to go get their sports nutrition products,” he said. “So, you really need to push the marketing side and make sure all the athletic people know you have them.” KNOW THE PRODUCTS Sports nutrition products have the potential to help your patients maximize their workouts, but only when used
RETAIL
correctly. Many of your patients might not know how to properly use them. “Have someone in your pharmacy who knows about the products, because patients are going to ask about them,” Ruby said. Like with prescriptions, you’ll need to help your patients understand the proper dosage for these products, and when they should take them. Having a staff member, especially a pharmacist, who can explain this information, will give you an advantage over other stores that sell these products. And, because the Food and Drug Administration (FDA) doesn’t hold supplements to the same standards as medications, some of these products might not make their benefits—or risks—completely clear.
Make sure you stock products from trusted manufacturers, and take the time to explain any potential risks to patients. ADVANCE HEALTH For Everett Pharmacy, a sports nutrition section seemed like a logical fit. It allows the pharmacy to serve a patient base that might not need prescription medications, or that might not want anything else from its front end. And in the end, it’s all about health. “Here in the pharmacy, we’re trying to promote health,” Ruby said. “Sports nutrition is just another way to do that.”
A Guide to Sports Nutrition Products There’s a good chance you’re already selling products in your front end that would tie in well with sports nutrition products, like multivitamins and mineral supplements. But for a true sports nutrition section, you’ll need much more. Here are some of the most popular types of sports nutrition products. 1. Carbohydrate drinks. Sports drinks, like Gatorade™, can help boost endurance and hydration over long periods of exercise. 2. Energy bars. These bars can help provide energy from carbohydrates before and during a workout. There are many different kinds, ranging from high-protein bars to bars specifically for women.
Most people like to mix them into shakes or smoothies, and they’re popular even outside the sports nutrition segment. 4. Amino acids. This supplement helps with muscle repair, recovery and growth when taken in conjunction with a workout. Common amino acid supplements include glutamine, isoleucine, leucine and valine. 5. Creatine. This supplement provides energy to muscles, and can help with repeated short bouts of intense exercise, like weight lifting.
3. Protein powders. All varieties of protein powders are intended to help build muscle when taken in conjunction with a workout.
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SOLUTIONS
At Your Disposal How to safely dispose of sharps in your pharmacy If your pharmacy offers—or is looking to start—an immunization program, you’ll need a system to properly dispose of used sharps. While hospitals, doctors’ offices and long-term care facilities have had disposal systems in place for years, managing sharps disposal is fairly new for pharmacies just getting into immunizations. As an increasing number of pharmacies administer immunizations, more pharmacies are generating medical waste—and pharmacists might not know the best way to dispose of it. “Pharmacies need to understand what their options are for disposing of sharps,” said Jan Harris, director of environmental health and safety at Sharps Compliance, Inc., a medical waste services company. “In no state are you allowed to throw your needles into the trash. Pharmacists need to make sure they’re doing everything right.”
KNOW YOUR OPTIONS Pharmacies typically have two options for safe sharps disposal: a pick-up service or a mail-back company. With a pick-up service, the company comes to your pharmacy, picks up your sharps container, and then transports it to a disposal facility. “A pick-up service is perfect for a large generator,” Harris said. “But for a pharmacy, it’s a little bit cumbersome and typically expensive.” A mail-back company makes more sense for smaller generators, like pharmacies, she said. It works like this: You purchase a pre-addressed sharps container from a medical waste disposal company. Then, you fill it up, complete the paperwork that came with the container, and mail it in. It goes straight to the disposal facility. The benefits of using a mail-back company are significant. You stay in control; there’s no contract to sign; and it’s a convenient and easy process.
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SOLUTIONS
Regulations to Know
Mail-backs are cost-effective for pharmacies because you can purchase containers as you need them, which gives you flexibility as demand for immunizations fluctuates throughout the year. For pharmacies that use mail-back services, it’s important to keep in mind that some states’ laws limit the amount of time medical waste can stay on-site. So, be sure to mail back the container in a timely manner. The most common sharps disposal system used in a retail pharmacy, according to Harris, is a two-gallon mailback container. It’s a Food and Drug Administration (FDA) approved sharps container that comes in a pre-labeled, pre-paid shipping box. “It’s a good size; it’s got a handle; it’s easy to store, and it’s easy to bring out for immunizations,” Harris said. BEST PRACTICES Not all states have laws about the storage or handling of sharps containers, but you should still be precise about where you place it. “Take your container behind the counter, keep it in the shipping box, and put it in a cabinet or an area that’s secured,” Harris said. “To go a step further, put a biohazard label there. This way, you can be sure that your sharps container isn’t being mishandled and won’t be misplaced.” When you need to administer a vaccine, take your sharps container with you so you can immediately dispose of the syringe. But don’t forget to put it back in its place. “Your sharps container needs to have a home, just like your fire extinguisher has to have a home,” Harris said. “You always need to know where it is.” EDUCATING PATIENTS In addition to properly disposing of sharps used in your pharmacy, your patients who use needles will likely ask you how they can dispose of their sharps. Educate your patients about why they shouldn’t put sharps in the trash, down the toilet or in the recycling bin. And, help them obtain sharps containers, and find safe disposal programs.
“The problem with regulations on medical waste,” said Jan Harris, director of environmental health and safety at Sharps Compliance, Inc., “is that there are quite a few, and they’re different in every state. But, it’s important to get on board regulatory-wise.” When going over your state’s regulations, watch out for these important requirements. 1. Are you required to register as a generator? 2. Do you need to maintain a plan for waste management? 3. How, and when, do you complete and sign the manifest tracking form? 4. Are there any specifications for labeling information? If you’re unsure of where to find the regulations for your state, Sharps Compliance, Inc., offers a state regulatory map with direct links to each state’s medical waste regulations. Find the map at sharpsinc.com/regulatorycompliance.
The FDA offers information on its website (fda. gov) to help patients understand how to properly dispose of sharps. It even features free printable pamphlets, posters and inserts you can use in your pharmacy. “You have to have policies on how to help your patients,” Harris said. “Have a solution to help them in your pharmacy, or have an answer for them on where they can dispose of their sharps.” “The pharmacist is so trusted, probably more than the doctor,” she said. “People expect the pharmacist to be able to help.”
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Pharmacy Expansion The how-to’s, challenges and benefits of opening additional pharmacy locations By Kathleen Barbosa
Summers Pharmacy, an independent community pharmacy in Clinton, Mo., had only been open a few weeks when a local hospital presented an opportunity. Golden Valley Memorial Hospital contacted Ryan Summers, Pharm.D., co-owner of Summers Pharmacy, about opening a second location at its clinic. Another independent pharmacy that held the space for 20 years had just closed down, and the hospital wanted to replace it.
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“The hospital, the clinic, the patients and the physicians were all used to having a pharmacy there,� Summers said. The hospital was considering putting in its own outpatient pharmacy, and Walgreens was also looking into opening a location in the space, but Summers said the hospital wanted to know if he and his wife and coowner, Julie Summers, Pharm.D., were interested first. This seemed like an opportunity for Summers
Pharmacy to make a bigger impression on the community, to keep the physicians happy and to prevent competition from entering the clinic. “We started looking at it and thought we could open one up and be successful,” Summers said. Just four months after opening its original location, Summers Pharmacy opened the doors to its second location at the hospital clinic on Aug. 1, 2013. “It wasn’t easy, but it wasn’t that bad either,” Summers said. Opening an additional location can be beneficial for independent community pharmacies, but how do you know when, where, and if you should open another location? Three independent community pharmacy owners share their insights into growing their businesses by opening additional locations. HURDLES YOU’LL FACE Opening an additional location presents no shortage of challenges for independent community pharmacy owners. When starting out, independents can face shortages of essential elements, namely staff and capital. “What prohibits many independents from opening up another store is probably staffing,” said Chris Schiller, Pharm.D., vice president of operations at Economy Pharmacy, an independent community pharmacy with four locations in Oklahoma. It can be difficult to stretch your current staff to fill a second location, so opening another location often requires hiring more people. The cost of the new staff, the physical location, the equipment and the inventory you’ll need, can add up to another common problem—capital. Opening a second location requires enough cash flow to stay in business while you’re working to attract new patients. “It takes a while to start making money from zero, especially with how much it costs to start up,” said Schiller, who has helped open two additional locations for Economy Pharmacy. “Independents have to have enough capital to be able to make it until they become profitable. That’s the biggest challenge.” Geography created an additional hurdle for Schiller. He helped open Economy Pharmacy’s third and fourth locations in Tulsa, Okla.—an hour away from the two
other locations in Muskogee, Okla. “Being in a new city, I didn’t know the doctors, and even though we’re not very far away, the cultures were a little different,” Schiller said. For Summers, the location in the hospital clinic—in the same town as the original pharmacy—was ideal. It created access to new patients in the same community, and it helped the pharmacy build relationships with the hospital staff and with local physicians. But, there was a catch. “The previous lease for the pharmacy there had got to the point that it wasn’t really beneficial to the pharmacy. It was pretty drastic,” Summers said. “So, obtaining a lease that was beneficial to the pharmacy and the hospital, and then getting a pharmacy manager to operate the pharmacy were our biggest challenges.” When Koby Prater, Pharm.D., owner of Prater’s Pharmacy in Seneca, Mo., bought out the owners of Bruner’s Pharmacy in Webb City, Mo., he thought he was prepared. “I planned quite a bit before we took control of it,” Prater said. But despite his plans, unexpected challenges emerged. “A lot of things came up that weren’t foreseen,” he said. “The new pharmacy had charge accounts that were out of control that we had to rein in. We’re still working on that and it’s been about six months.” ESTABLISHING UNIFORMITY Creating consistency is another challenge of owning multiple pharmacy locations. Summers said he had to train the staff at his new location to adhere to the same procedures as the main location. “We obtained a lot of the same staff that the clinic location had previously, so some of them had to make some adjustments,” he said. Prater had a similar situation. He said initiating new policies at Bruner’s Pharmacy took six to eight weeks, and even longer in some areas, because employees were used to the policies their previous pharmacist used for 30 years. “The technicians weren’t being utilized to their full potential, so even though they had worked there a long
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Pharmacy Acquisition Financing Checklist If you’re looking to open an additional pharmacy location, make sure you’ve taken these steps before starting the financing process. Identify the pharmacy you wish to acquire. Identify a pharmacy that has a solid customer (prescription) base. Is there an opportunity to grow the business? Is this the pharmacy for you? Perform high level due diligence. Analyze the types of prescriptions being filled. Make sure you are comfortable with the product mix (controlled substance volume, durable medical equipment, compounding and workers compensation.) Determine the Net Operating Income (NOI) of the pharmacy. This is defined as income after all operating expenses are deducted from gross margin, but before income taxes and interest are deducted. Determine the value of the pharmacy. A pharmacy is worth what a buyer is willing to pay for it (in cash), or what a lender is willing to finance. It must produce a cash flow sufficient to repay the loan. Every situation is different, but lenders generally want to see at least 25 percent
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more cash flow than is required to service the loan. Execute an agreement with the seller in writing, “Letter of Intent” or “Term Sheet.” This outlines the terms and conditions related to the acquisition, executed with the assistance of your legal advisor or attorney. Ultimately, after the term sheet is executed, it will guide your legal counsel in creating the final purchase agreement. Obtain prequalification for financing. Get prequalified for a loan amount that will cover both your project development and working capital costs. You should feel confident knowing you have adequate capital to manage your business, and to repay your debt. Initiate the Asset Purchase Agreement with your attorney. With your tax planning arranged, you should consult with an industry-specific attorney to draft the purchase agreement. Once you have followed the steps in this checklist, talk with your lender about your financing needs and the type of loan that will work best for you. Courtesy of Jimmy Neil, general manager of the pharmacy division at Live Oak Bank
time, they basically had to learn their jobs all over and learn how to do a lot more,” Prater said. A SUBSTANTIAL INVESTMENT Like all new ventures, opening a new location requires a financial investment. Looking at your current expenses can help you project what the minimum financial investment of opening a new location will be. “I would estimate it costs at least six to 12 months of operating expenses,” Summers said. “Just add all those first year expenses together and that’s how much you’re going to go into the hole essentially.” New licenses, insurance and contracts also have to be figured into the financial and time costs of opening a new location. “It takes a lot of paperwork and time, getting all the forms and contracts filled out,” Schiller said. “That’s probably one of the biggest challenges.” For Prater, the time dedicated to training staff, attracting new business and addressing unexpected issues was the biggest investment. “No matter what you think, you will be busier than you were,” he said. The physical site of your new location can also inflate your cost and time investment. “I like to have a hand in both places, but I can only be in one place at a time,” said Prater, whose second pharmacy is about a 30-minute drive northeast from his first location. Taking over Bruner’s Pharmacy had its own set of financial challenges for Prater. “Initially, when we took over, they had a different computer system so we changed the software over, and changed the workflow around, and we also changed wholesalers,” he said. If you’re unsure what level of time and capital you should invest, Prater recommends asking the experts to guide your investment. “I have a good consultant who ran cash flow models for me and said we needed a certain number of patients and prescriptions,” he said. This analysis helped him determine that it was feasible to take over the new
location, and it set benchmarks for how many scripts and patients the new location would need to be profitable. Schiller, on the other hand, learned the challenges that come with leasing or building when he opened new stores for Economy Pharmacy. “If you’re leasing, you’ll need your inventory, computer, and a build out, so you’re talking probably $400,000,” Schiller said. It took Schiller about six months to open a new location with a lease, and an entire year when the store was built from the ground up. “If you build a store from the beginning, you’re talking a couple million dollars,” he said. Building and leasing each have pros and cons. With the leased store, Schiller was able to open a lot faster, but each month’s rent cuts into profits. The custombuilt store cost more upfront and took longer to build, but Schiller said designing everything exactly how they wanted was a big benefit. GETTING NEW BUSINESS No matter how much work you do ahead of time, one factor can make or break a new pharmacy location— whether or not you can get patients. “When you open a new location and you’re not purchasing a pharmacy that’s already established, you start out with zero prescriptions,” Schiller said. “The biggest thing is attracting new business.” And, attracting new patients to your new location— not just shuffling patients from your current location—is essential to success. “Opening another location and taking patients from your first location to that location doesn’t really benefit you,” Summers said. “You’re just adding costs to fill those prescriptions.” “We wanted to get extra prescriptions, so the clinic location was good for that,” Summers said. “We were able to get antibiotics and pain medications, those sort of first fill medications that would have possibly gone to Walgreens or Wal-Mart.” “We’re hoping that those first fills lead into more
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future fills at either that clinic location or the main location,” he said. But they didn’t just sit and wait. Summers said he marketed to new patients by sending out flyers and direct mailers to promote the new location. “One of our new slogans we used for the second location was ‘two locations to better serve you,’” he said. Summers Pharmacy used the slogan on social media, on its prescription sacks and on advertising in the local newspaper. Along with attracting new patients, Prater said one concern at Bruner’s Pharmacy was keeping current patients once he took over. “In any ownership transition, it’s okay if the patients know it’s changing owners,” Prater said. “But hopefully you can make it seamless enough that they don’t even know there’s been a change.” FACING THE COMPETITION Whether your new location is in a familiar place or in a new city, you’ll likely face competition. Prater’s main location in Seneca, Mo., is the only pharmacy in town, but when he took over Bruner’s Pharmacy in Webb City, Mo., he faced new competition from Walgreens, Wal-Mart, grocery store chains and other independents. Despite the increased competition, Prater said he runs both locations the same way. “I think it comes back to customer service in both locations,” he said. Schiller said he thinks independents should actually consider opening a second location in an area where they’ll compete with big chains. “I think there’s a good opportunity for independents, especially in a big city,” Schiller said. “Since I’ve moved from Muskogee, which had 38,000 people, to Tulsa, which is a much larger city, it’s easy to get business from chain customers. People are often intimidated by the chain pharmacies, but it’s actually a very good opportunity for independents.” To determine if a second location is getting enough new business from the competition, Summers recommends setting and tracking goals. “If the new location doesn’t hit the goals and timelines, you have to be willing to close it,” he said. “If
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you’re not able to close it, you can’t risk opening it.” Summers offered one key piece of advice to any independent pharmacy considering opening a new location in a big or small city. “Be willing to compete, and if you’re able to take care of the patients, they’ll come to you,” he said. SEEING THE BENEFITS All this investment—the time, the money and the effort— can yield several business benefits. Economy Pharmacy opened its first two locations in the same town of Muskogee, and Schiller said having two stores made it possible to go back and forth between locations to get patients the medications they needed. “It’s such a huge benefit for inventory,” Schiller said. “If I don’t have something, my other store is probably going to have it.” “When I opened our first store in Tulsa, it was the only store, so I was kind of at a disadvantage to the chain drug stores,” he said. “If I didn’t have something in stock, I couldn’t get it until the next day, but now that I have two stores in Tulsa, it’s a huge advantage.” Prater’s Pharmacy found that adding another location meant better deals when ordering products. “Buying power is one of the big benefits,” Prater said. “With common ownership, your revenue gets lumped together, so you get a better cost of goods.” THE DECISION There’s no simple metric that can tell you if you’re ready to open a second location, but you can learn from the advice of those who have done it. Summers said pharmacy owners should consider where new prescriptions would come from before opening another location and to pay attention to patients’ attitudes, because they can signal an opportunity. “You get a feel from the patients if they’re not being taken care of at other pharmacies,” he said. “If you’re getting a lot of transfers or hearing a lot of rumbling from patients, then there’s a way to get new patients.” Even if there’s an opportunity, Summers said the main location has to be in good shape before you open a second. “Don’t do anything unless your main location is running smooth and it can handle the owners, or the manager, being away from the main pharmacy during the
opening process,” he said. “You have to have things in order at your main pharmacy before you can open up a second location.” For Prater, deciding to open a second location began by asking questions. “Am I ready for this? Is this something that I really want to do? Do I have the time and the manpower to commit to doing this?,” he said. Prater said pharmacy owners should ask themselves these questions when deciding if they’re ready for the investment that a second location requires. Schiller recommends learning more about your area’s population and demographic makeup to determine if your community can support another pharmacy. “If there’s a town of 36,000 and there’s 14 pharmacies, they might not be able to support another one, no matter how much medicine they take,” he said. LOOKING TO THE FUTURE Once you open a second pharmacy location, you may find you’re always on the lookout for another opportunity. At least that’s how it is for Summers, Schiller and Prater. Summers Pharmacy is already in the process of opening a third and fourth location. One of the acquisitions is still in the works, but Summers is in the final stages of opening a pharmacy in Butler, Mo. “An opportunity just popped up a month or two ago to get into that community,” Summers said. “They had an independent pharmacy in town and a Wal-Mart pharmacy in town. I’ve never heard of this happening before, but the independent pharmacy owners just disappeared. They literally just walked away and left the community and patients high and dry.” “I think that community likes having an independent pharmacy,” he said. “We want to get in there and provide that high level of service they’re used to.” Prater and Schiller both said they don’t have any set plans for opening additional locations, but they’re not saying “no” to an opportunity either. “I’m thinking probably in the next year or year and a half of opening up another location,” Schiller said. “I’m always looking for a good location and a good opportunity.”
Numbers to Know Take a look at the trends for the average independent community pharmacy to see how your pharmacy compares. 27 – Percent of independent community pharmacy owners who have ownership in two or more pharmacies 1.71 – Average number of pharmacies in which each independent owner has ownership 8.3 – Average number of non-owner, full-time employees per pharmacy location $3,892,702 – Average annual sales per pharmacy location 62,424 – Average number of prescriptions dispensed per pharmacy location Source: 2014 NCPA Digest (Based on data from 2013.)
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SPOTLIGHT
Meter features When it comes to meters, patients are faced with numerous options. How do you know what to tell patients when they ask for a recommendation?
Diabetic Sales Offering supplementary products for patients with diabetes can boost revenue Every patient is equally important to you as a pharmacist, but for an independent pharmacy business, patients with certain disease states are more profitable than others. And few conditions are more profitable than diabetes, largely due to the nature of the disease. “Typically, a patient with diabetes will visit the pharmacy more often than a person who doesn’t have diabetes,” said Michael Schlanger, senior marketing manager – channel marketing at Nipro Diagnostics, a manufacturer of blood glucose systems and supplementary health and wellness products for people with diabetes. “They fill more prescriptions, and they have more co-morbidities that go hand-in-hand with it.”
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“The key with blood glucose meters is the quality and the value to that consumer,” said Michael Schlanger, senior marketing manager – channel marketing at Nipro Diagnostics. “Every meter has to meet standards set by the Food and Drug Administration (FDA), but beyond that, it’s about what meter best fits the patient’s lifestyle.” Here are a few features to recommend. 1. Ease-of-use 2. Proven accuracy and performance 3. A reputable company to ensure there isn’t a supply chain interruption 4. Event tagging to put blood sugar in context of life events, including exercise, illness, and pre- or post-meal 5. Bluetooth and download capabilities to share data
Tailoring your pharmacy to address the numerous health issues associated with diabetes isn’t a one-time gain. “Patients are tethered to that pharmacy because of their increased need for interconnected preventative and maintenance-based solutions, and the products you
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SPOTLIGHT
5 Diabetic Products to Consider Offering
recommend as a pharmacist,” Schlanger said. Focusing on this disease state enables you to help patients and improve your bottom line at the same time.
Having a diabetes section in your pharmacy is a start, but pharmacists can take it a step further. Maximize your diabetic product sales by explaining to patients why they need supplementary products beyond meters and test strips. Here are five additional products to stock.
INVEST IN EDUCATION “Imagine you’re standing in front of the pharmacy shelf as a newly diagnosed person with diabetes,” Schlanger said. “There’s an overwhelming amount of products that are vital to all aspects of diabetic care, and many patients don’t know where to start.” Part of selling supplementary diabetic products is education. “You want the patient to understand that there’s more than just blood glucose testing,” he said. “There are multiple facets of care involving a multitude of products that pharmacists can help with.” “Diabetes is such an invasive condition because it affects how you eat; it affects your skin; it affects your eyes,” Schlanger said. And, addressing these problems requires the right products. Without proper guidance, patients might select less effective products. For example, reusing a lancet or syringe, which could increase the risk of infection. Or, eating candy, rather than fast-acting glucose products, like tablets, gels, or shots, to raise blood sugar during a hypoglycemic event.
1. Lancets What they need: A new lancet for every test. Why: Reduces the risk of infection and pain. 2. Supplements What they need: A daily fiber supplement. Why: Adds nutritional support and slows the uptake of sugar into the bloodstream. 3. Skin care products What they need: A daily deep-moisturizing skin care regimen. Why: Diabetes can shrink the nerves in the periphery causing the inability to sweat properly, leading to dry or cracked skin that can cause infections and other complications. Also, a daily lotion regimen gets patients in the habit of checking their skin for wounds. 4. Glucose products What they need: A fast-acting glucose tablet, gel or shot, containing a pre-measured amount of a fast-acting carbohydrate. Why: It raises blood sugar during a hypoglycemic event without causing a blood sugar spike. 5. Syringes What they need: A silicone-coated syringe with no surface imperfections, and various gauges and lengths. Why: A quality syringe ensures a comfortable patient experience, and proper length is key for injecting insulin correctly.
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A DIABETES DESTINATION To best serve your patients with diabetes, Schlanger recommends providing all diabetes-related products in one central area in your pharmacy. “Patients want a diabetes destination,” he said. “They’re seeking a very simple section of the store that shows them everything they may need, and that has an education component to it. They don’t want to have to march down multiple aisles throughout the store to get what they need.” Your diabetes front-end section should clearly define what each individual product is and why patients need it. Also, consider placing educational signage or brochures near related diabetic products. Do this for blood glucose meters, but also do it for fast-acting glucose products, lancets, skin care and foot care. Your front-end diabetes section can help patients find products that are ideal for them, but patients also need your expertise to make sense of it all. “Pharmacists tie the products on the shelf together,” Schlanger said.
MONEY
Chip In Is your pharmacy prepared for the switch to chip cards?
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By Chloe Holt
Chip-and-Dip
Credit cards are changing. And so are the ways you can accept credit card payments in your pharmacy. By October 2015, millions of Americans will no longer be using magnetic stripe credit cards. Instead, they will have EMV cards. These are also known as “chip” or “smart” cards. The Payments Security Task Force estimates that 63 percent of all credit and debit cards in the U.S. will contain EMV chips by the end of 2015, and that 98 percent will be EMV-enabled by the end of 2017. EMV, which stands for Europay®, MasterCard® and Visa®, is the
Card swiping will soon be a thing of the past. Card dipping is the standard for chip cards. Here’s how it works.
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1. Insert the card into the EMV slot, face-up and chip-first. The EMV slot is usually at the bottom of the terminal. 2. Keep the card in the slot until the transaction is complete. Currently, the average transaction length for EMV cards is 10 seconds, so remind your customers to be patient.
3. If it’s a chip-and-PIN card, the customer will be prompted to input his or her PIN. However, most chip cards in the U.S. are chip-and-signature, not chipand-PIN. 4. The transaction will occur as the chip and the reader create a onetime encrypted code. 5. Depending on your terminal, the customer may be required to sign for the transaction, unless he or she has a chip-and-PIN card. 6. The receipt will print. 7. The card can now be removed from the EMV slot.
MONEY
Pharmacy Liability When is your pharmacy liable for fraudulent charges? It depends on the type of transaction. Here’s a guide. You will be liable for: Chip cards processed at a magnetic stripe terminal
You will not be liable for: Chip cards processed at a chip terminal Magnetic stripe cards processed at a chip terminal Magnetic stripe cards processed at a magnetic stripe terminal Keyed-in and online transactions
Source: EMV 101: What Small Businesses Need to Know About the Switch to Chip Card Technology, A webinar by Square ® and the U.S. Small Business Administration
global standard for the interoperation and acceptance of secure payment transactions. Originally written in 1993 and 1994, the standard is now managed, maintained and enhanced by EMVCo, a consortium consisting of American Express®, Discover®, JCB, MasterCard®, UnionPay and Visa®. Magnetic stripe technology—the same technology used in cassette tapes—is outdated, and has left credit card users in the U.S. vulnerable to fraud. According to a report from Barclays, half of all credit card fraud worldwide happens in the U.S., even though only 25 percent of all credit card transactions take place in the U.S. These fraudulent transactions cost the U.S. upwards of $8.6 billion a year. Other countries, including most European countries, began transitioning to chip cards in the 1990s. Now, the U.S. is catching up. In October 2014, President Obama announced the Buy Secure Initiative, a movement designed to speed adoption of EMV technology in the U.S., and credit card companies are working to comply as quickly as possible. As they continue to replace customers’ magnetic stripe cards with chip cards, they’re encouraging merchants—including independent community pharmacies—to update their card reader technology, too. Credit card companies have set a soft deadline of Oct. 1, 2015 for businesses to upgrade to EMV technology. For those that don’t, liability for fraudulent transactions that occur as a result of the use of an EMV card on a stripe card reader will shift from banks and credit card companies to the businesses themselves. While there’s no law or regulation that will require you to have EMV technology in your pharmacy, processing EMV transactions sooner, rather than later, can only benefit your business. Here’s what you need to know about EMV before the October deadline. MORE SECURE TRANSACTIONS With magnetic stripe cards, information about the bank, card and account is stored on the stripe. Because the information stored on the stripe is never changed, hackers can easily extract all the account information, and copy the stripe onto a fraudulent card. With EMV cards, however, a unique, one-time code is created for each transaction. The code can’t be reused,
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so it’s useless if copied or stolen. And, the data is encrypted both in the chip and at the EMV reader, where the customer pays. While fraudulent charges are still possible with EMV cards, the technology makes it much more difficult for hackers to steal usable data. CULTURE SHIFT Credit card payments are transitioning from “swipeand-sign” to “chip-and-signature,” and eventually to “chip-and-PIN.” This means that the speed and ease your customers—and you—have come to expect from credit card payments are a thing of the past. Instead of swiping their cards and putting them away, customers with chip cards will leave their cards in the terminal for the entirety of the transaction, which can take up to 10 seconds. Educate yourself, your employees and your customers on how chip-and-signature transactions work. It will take time for everyone to get used to the new system, and you’ll have to be diligent about making sure transactions are processed correctly. EMV AND YOUR PHARMACY Because EMV cards are still being manufactured with magnetic stripes, you’re still able to process chip cards on a magnetic stripe terminal. You’ll just be liable for any fraud resulting from these transactions. To avoid this liability, you’ll want to update to a system that is EMV-enabled and use the EMV reader to process chip card transactions. Putting this technology in place by the October deadline has been a top priority for point-of-sale vendors, so check with your pharmacy’s vendor for more information about how you can update your system.
Chip Cards vs. Magnetic Stripe Cards Will you know a chip card when you see one? Here are three things you should know about the appearance of chip cards versus the appearance of magnetic stripe cards. 1. Chip cards are identifiable by the chip on the front of the card, but they are the same size and thickness as magnetic stripe cards. 2. Both credit card types have magnetic stripes. Credit card issuers, wary of changing too much too quickly and disrupting payments, are still equipping chip cards with magnetic stripes to ease the transition, and so that consumers can use their chip cards at locations that haven’t yet updated their systems. 3. Both cards require the back of the card to be signed for security reasons. 1.
B. PARKER
2.
3.
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OUTLOOK
Pharmacy Accessibility Creating an inclusive pharmacy for individuals of all ability levels By Jennifer Salva
Now’s the time to make sure your pharmacy is not only complying with disability regulations, but also going above and beyond to serve a key portion of your patients. This year marks the 25th anniversary of the Americans with Disabilities Act (ADA), which was signed into law in 1990 and made unprecedented improvements to the quality of life for millions of Americans living with disabilities. “For the past 25 years, the ADA has made a positive difference in the lives of those who have disabilities by ensuring better access to buildings, transportation, and employment,” Georgina Peacock, M.D., M.P.H., director of the Centers for Disease Control and Prevention’s Division of Human Development and Disability, said in a July 2015 press release. Today, individuals with disabilities account for 18 percent of the U.S. population, making this group the largest minority in the U.S. And, the number of individuals who live with a disability will continue to grow as the baby boomer generation ages. As an independent community pharmacy owner, manager or pharmacist, you don’t want to unintentionally exclude a large portion of your community from using your services—and consequently losing business. While it’s your responsibility to comply with the requirements established by the ADA, you can take steps beyond your legal obligations to create a comfortable environment for individuals of all ability levels in your pharmacy. Complying with these recommendations can create a more inclusive pharmacy, while also helping you gain new, loyal patients. KEYS FOR ADA COMPLIANCY The ADA states that, “no qualified individual with a disability shall, by reason of such disability, be excluded
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Disability in the U.S. 13 percent of adults have impaired mobility 10.6 percent of adults have impaired cognition 6.5 percent of adults have independent living challenges 4.6 percent of adults are blind or visually impaired 3.6 percent of adults have difficulty with self-care Source: Centers for Disease Control and Prevention, Disability Impacts All of Us infographic
from participation in or be denied the benefits of services, programs, or activities of a public entity, or be subjected to discrimination by any such entity.” As a business, your pharmacy is required to make “reasonable modifications” in both policy and procedure to accommodate those with disabilities, so they can use your store and services. From the entryway to the front end to the pharmacy counter, here are some key ADA requirements to meet— and exceed—to create a pharmacy that individuals of all abilities will want to give their business to. PARKING AND ENTRANCE The number of accessible parking spaces your pharmacy is required to provide depends on the size of your parking lot. If your pharmacy has 26 to 50 spaces, you’re required to have at least two accessible spots, and at least one for parking lots with one to 25 spaces. If you have a small lot of four or fewer spaces, you still need to have one accessible parking spot, but there’s no accessible parking signage required. So, what makes a parking space “accessible”? Accessible spaces must have an access aisle, which allows a person using a wheelchair to get in and out of his or her vehicle.
OUTLOOK
Even just one step outside your entrance could prevent potential patients who use mobility devices from entering your business. Installing a ramp, lift or railing along the walkway can provide accessibility. Or, you could create a second entrance if the main entrance isn’t accessible. If you have multiple entrances to your pharmacy, you’re required to post signage to indicate which entrances are accessible. AISLES, SHELVING AND COUNTERS The path a patient who uses a wheelchair or mobility device takes through your pharmacy is known as an “accessible route,” and must be at least three feet wide. The accessible route can only be blocked for temporary interruptions, such as restocking your shelves. During this time, you or a staff member must be available to assist the patient in retrieving items from the blocked area. The ADA does not restrict the height of shelves or selling space, but keep those who use mobility devices in mind when arranging and stocking your front-end shelves.
Make sure an employee is available to help patients locate and reach items that are too high or too low. ACCESSIBLE COMMUNICATIONS Because disabilities are unique to every person, flexible communication skills are essential for positive interactions with your patients with disabilities. “In order to provide equal access, a public accommodation is required to make available appropriate auxiliary aids and services where necessary to ensure effective communication,” according to the ADA. “The type of auxiliary aid or service necessary to ensure effective communication will vary in accordance with the length and complexity of the communication involved.” Systems your pharmacy already has in place, such as text message refill reminders, may eliminate some challenges for individuals who are deaf or hearing impaired. And, many patients with vision impairment use read-aloud apps for their smartphones. Still, you and your employees need to be prepared to accept phone calls from a Text Telephone (TTY), which
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OUTLOOK
Disability and health Your patients with disabilities are potentially at risk for other health ailments. Here’s a look at it by the numbers.
With disabilities Obesity 38.4% Smoking 30.3% High blood pressure 41.7% Inactivity 36.3%
Without disabilities Obesity 24.4% Smoking 16.7% High blood pressure 26.3% Inactivity 23.9%
Source: Centers for Disease Control and Prevention, Disability Impacts All of Us infographic
individuals with a hearing or speech impairment may choose to use. Writing notes with someone who is deaf or hearing impaired may do the trick for simple transactions, but complex medical conversations may require the use of an interpreter. If you’re using an interpreter in-person, as opposed to remote video interpretation, make sure to speak to the individual—not the interpreter—and make eye contact with her as she signs back to you. If you live in an area with a large deaf population, consider hiring a staff member who speaks American Sign Language (ASL). Even if you only have one or two patients who are hearing impaired or deaf, try learning a few simple greetings or questions in ASL. Just as you learn facts about individual patients’ lives, like the names of their children or where they work, learning a few greetings in ASL can show that you take a personal interest in your patients.
Also, be prepared to help individuals who are visually impaired or blind find products and read labels. It may also benefit individuals with an intellectual disability to hear labels read aloud or to receive additional explanation of instructions. You can also make your informational pamphlets and other materials more accessible by offering them in large-print versions for the visually impaired. IMPROVING INTERACTIONS It’s important for all employees at your pharmacy to know how to speak to patients about their disability. The ADA Update: A Primer for Small Business provides helpful outlines for speaking with patients about their disability. Consider adding it to your employee training materials. Perhaps an individual enters your store, and you are doubtful that he really depends on his assistive device. According to the guide, it’s not permissible to ask individuals about their disabilities, unless you’re discussing their needs pertaining to their medication or medical supplies. A situation could arise, however, when you must tactfully inquire about an individual’s disability. For example, if an individual enters your pharmacy with a presumed service animal, you may only ask two questions: “Is the animal required because of a disability?” and “What work or task has the animal been trained to perform?” Another situation where the need to explicitly discuss a patient’s disability is if she is using a powered device for transportation that’s not intended for disability assistance, such as a motorized scooter or segway. “Public accommodations must allow individuals who use these devices to enter the premises unless the business can demonstrate that the particular type of device cannot be accommodated because of legitimate safety concerns,” according to the guide. If a situation arises when you may question the use of a piece of assistive-equipment, remember to remain patient and respectful at all times, as not all disabilities are visible. For a comprehensive guide on all of the requirements for ADA-compliance, visit ada.gov. A small business guide for ADA regulations is also available at ada.gov/ smbusgd.pdf.
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NOTES
Flavor of Engagement Improve patient loyalty and trust with a personalized service Offering to personalize the taste of a medication can do more than make your patients more compliant. It can help you engage with your patients by transforming a simple purchase into a meaningful interaction. “We want pharmacists to go beyond just waiting for the customer to ask them for tips on how to make medicine time less stressful,” said Chris Cielewich, vice president of independent accounts at FLAVORx, a company that allows customers to personalize the taste of their medication in pharmacies. “We want the pharmacist to start that dialogue.” Some pharmacists hesitate to suggest this service to patients because it’s an added charge, and they don’t want to feel like salesmen. “But if you start to think about personalizing the taste as a solution, then it becomes a way that the pharmacy can help deliver a less stressful medicine-taking experience for both parents and their children” Cielewich said. FROM COMMODITY TO SERVICE Cielewich suggests pharmacies engage with patients by turning a commodity purchase into an experience. “Amoxicillin is the same drug in 60,000 pharmacies across the country, but the pharmacies that choose to engage with customers, by asking children to choose how their medication will taste, they’re turning that commodity into a service,” he said. “And, ultimately into an experience.” Improving the medicine-taking experience for kids—and making parents’ lives easier—can help build trust and loyalty between patients and pharmacists, Cielewich said. ACHIEVE COMMON GOALS Besides improving the experience, changing the medication’s taste can help you work with parents to
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Offering customizable taste as a part of your pharmacy’s service profile can help you connect with patients. achieve a common goal—getting kids to simply take their medicine. “A lot of times parents are embarrassed to ask, ‘How can I get my kid to take his medicine?’” Cielewich said. Don’t wait for parents to ask. Suggest it to them. “Letting children choose the taste of their medication helps kids take control of the situation, which improves their willingness to complete the whole course of the medication,” Cielewich said. Offering additional suggestions is another way you can help parents. For example, suggest they reward their child with a small prize for finishing the medication. Cielewich said this advice can help achieve the real objective. “You’re really, genuinely looking for patients to get better—and stay better,” he said. CREATE ALLIES By including customizable taste as part of your pharmacy’s service profile, you can create mutually beneficial relationships between you and your patients. “Promote these services to really get customers to become advocates for your pharmacy,” Cielewich said. “Offer patients an experience that’s above and beyond their expectations, and then ask them for reviews,” he said. “The more you can interact and engage with the customer, the more you’re going to build value for longterm loyalty and success.”
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