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ELEMENTS DEPRESSION SCREENINGS One study reveals how paying pharmacists for mental health screenings can save lives

PRESCRIPTION LOGS How to use prescription dispensing logs to better manage your pharmacy business

Collaborative Care How collaborative practice agreements make patient care more efficient and accessible VOL. 6 ISS. 4 | DEC 2017 | PBAHEALTH.COM/ELEMENTS

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The business magazine for independent pharmacy

STAFF & CONTACTS Matthew Shamet – Publisher and Editorial Director Kirsten Hudson – Editor Paige Fisher – Graphic Designer Greyson Honaker – Contributing Writer Torrie Wright – Copy Editor INTERESTED IN ADVERTISING? elements@pbahealth.com

Contents Departments 22 SPOTLIGHT:


Adverse Events Pharmacists play a pivotal role in the FDA’s adverse events reporting strategy.

Pharmacy + Market How one pharmacy found its niche in a thriving downtown community. 26 MONEY:


Digital Marketing Why independent pharmacies can’t survive without promoting their businesses online.

Prescription Logs How to use prescription dispensing logs to better manage your pharmacy business. 31 OUTLOOK:


Brand New How to shape patients’ perceptions of your pharmacy through better branding.

Trend Spotting A look at the most important independent pharmacy trends for 2018. 34 NOTES:


Depression Screenings One study reveals how paying pharmacists for mental health screenings can save lives.


Biodegradable Vials How one pharmacy is making prescription dispensing more environmentally friendly.

Feature: Collaborative Care


How collaborative practice agreements make patient care more efficient and accessible.

Find more strategies, tips and expert advice to improve your business at pbahealth.com/elements.

15 Innovative Pharmacy Ideas Guaranteed to Set Your Business Apart

Discover the simple innovative pharmacy ideas that you can implement in your business right away. See how small changes can make a big difference. Read more at pbahealth.com/ innovative-pharmacy-ideas.

Elements magazine is published quarterly by PBA Health. Copyright© 2017 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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Adverse Events Pharmacists play a pivotal role in the FDA’s adverse events reporting strategy When patients experience adverse events from prescription drugs, the U.S. Food and Drug Administration (FDA) wants you to report it. The FDA hosts a database of adverse event reports, medication error reports and product quality complaints resulting in adverse events. The database, called the Adverse Event Reporting System (FAERS), enables providers and the public to report their experiences of adverse events. “FAERS reports help the FDA to monitor the safety of drug and biologic products once they reach the market,” said Tralisa Colby, a spokesperson for the FDA. WHY ADVERSE EVENT REPORTING MATTERS The FDA uses FAERS to identify and evaluate new safety concerns, to evaluate manufacturers’ compliance with reporting regulations and to respond to outside requests for information. “These reports may provide critical information that prompts a modification in use of the product, improves its safety profile and leads to increased patient safety,” Colby said. The FDA recently launched a new, user-friendly search tool that makes FAERS easier for providers, consumers and researchers to use. The update should help improve reporting and access to FAERS. “Improving data access and transparency are core concepts that drove the development of this FAERS Public Dashboard,” Colby said. The FDA said it hopes the increased transparency will help to encourage people and providers to submit better quality reports. “Complete and detailed reports are immensely helpful to the agency when identifying safety signals and choosing particular products for further analysis,” Colby said.

“Community pharmacists are very accessible healthcare professionals who are trusted by patients,” Colby said. “They are well-positioned to engage their patients in discussions related to safety concerns that might be related to a marketed product and obtain important adverse event information to report to the FDA.” Your singular knowledge as a pharmacist also makes you an invaluable resource. “By profession, pharmacists are the experts when it comes to drugs,” Colby said. “They play an important role in drug safety by increasing the number, as well as the quality, of submitted adverse event reports.”

By the Numbers

A look at the number of adverse event reports received by the U.S. Food and Drug Administration (FDA) in one year. 1,684,722 - Total reports in 2016 827,346 - Serious reports in 2016 (excluding death)

141,181 - Death reports in 2016 Source: FDA Adverse Events Reporting System (FAERS) Public Dashboard

Follow Elements magazine on Facebook and Twitter for pharmacy business tips and advice, news announcements, industry information and exclusive offers.

PHARMACIES’ ROLE IN REPORTING Pharmacists play a pivotal role in improving adverse event reporting because of their unique relationship with patients. ELEMENTS | pbahealth.com/elements



Digital Marketing Why independent pharmacies can’t survive without promoting their businesses online

Are you advertising where your patients spend most of their time? Adults spend 5.6 hours a day online, up 80 percent from 2010. And that data doesn’t just describe millennials—nearly 55 million Facebook users are over 54 years old. The importance of digital marketing grows every year. “Digital marketing is a must-do for pharmacies to survive,” said Susan Barrett, vice president of business development at Digital Pharmacist, a digital health company that powers the digital, communication and adherence solutions for more than 6,000 pharmacies, national pharmacy wholesalers, hospital systems and pharmaceutical brands. Digital marketing means marketing through digital methods. “The key objective is to promote the brand through various forms of digital media on a consistent basis,” Barrett said. “You want to be top-of-mind with patients to increase loyalty, in-store traffic and purchases.” Digital marketing drives new business and boosts current business. And it doesn’t require you to dig deep into your pockets. “It’s a cost-effective means to reach patients and acquire new patients,” Barrett said.


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UNDERSTANDING DIGITAL MARKETING Some methods of digital marketing are free or nearly free, including social media and email. But what you invest in digital marketing can pay for itself in returns. For example, Barrett said every $1 you spend on email marketing averages a $44 return-on-investment. Digital marketing allows you to target patients by demographics and geography. Targeting will drive qualified traffic to your website and increase mobile downloads, refill volume and new patients in your pharmacy. Barrett has seen the tangible results of digital marketing. Digital Pharmacist recently worked with one of its customers to execute a $5-off-the-purchase-of-$10-ormore promotion. The promotion included website, mobile app, newsletter and social media. “It drove 80 in-store visits in a few-day period,” Barrett said. Maybe your pharmacy already invests in traditional marketing. But how much are you spending? “You could be spending hundreds less reaching more new patients,” Barrett said. “Digital advertising with a strong emphasis in social media should account for at least 20 percent of your advertising budget.”

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Digital Defined

These low-cost digital marketing options can help independent community pharmacies run promotions, communications and advertising. Email and e-newsletters Budget-friendly and effective. Create an e-newsletter to send patients helpful health information and send email promotions on a weekly basis. Email promotions will drive instore traffic and health information will establish your pharmacy as a trusted resource. Mobile apps and text messaging Send patients refill and pick-up reminders through SMS text messaging. Or, take it to the next level with a branded pharmacy app. With an app, patients can refill their prescriptions, get refill and medication reminders, manage their profiles and family members’ medications, and receive health news and co-pay coupons. Search engine optimization Search engine optimization (SEO) seeks to elevate websites to the top of search results with

HOW TO GET STARTED Managing an effective digital marketing program takes time. And pharmacists already spend their days filling prescriptions, counseling patients and running a business. “That’s what they do best,” Barrett said. “They are the most trusted front-line point of health care.” For many pharmacists, digital marketing means navigating uncharted territory. “It’s a whole new industry to learn,” Barrett said. “That’s why you need a dedicated expert or you need to hire a reputable firm to do it because it’s a must in today’s digital age.” Companies dedicated to digital marketing, like Digital Pharmacist, can manage and execute digital marketing campaigns so pharmacies can focus on their patients and their business. But if you want to keep your digital marketing inhouse, Barrett suggests training a pharmacy technician to manage digital marketing and social media.

strategic keywords. If potential patients move to your area and search “pharmacy,” your website needs to rank on the first page of results. Or, you’ll lose that potential business to national chain pharmacies. Social media Create a free Facebook business page and post on a regular basis to increase ‘likes’ and ‘shares.’ For example, post about your employee of the month, publish holiday messages and stream live videos at community events. Website As the online face of your brick-and-mortar store, make sure your website is mobilefriendly, branded, user-friendly, feature-rich and informative.

For help, pharmacies can check out the Interactive Advertising Bureau at iab.com. It provides best practices and industry standards for digital advertising. PUTTING IT ALL TOGETHER Pharmacies need to run digital campaigns regularly, using a combination of channels to stay top-of-mind. A digital campaign could include an email informing your patients of a new service, an e-newsletter providing important health information, an e-coupon through your mobile app, an advertisement on Google and a special promotion for people who like your Facebook page. “Optimizing digital strategies on a consistent basis will make the pharmacy successful,” Barrett said. “That means sending promotions to drive in-store traffic and purchases at least once a month; sending e-newsletters to connect with patients on a weekly basis; and providing meaningful social media posts on a daily basis.”

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Brand New How to shape patients’ perceptions of your pharmacy through better branding How do patients view your pharmacy? Do they think of you as innovative and tech-forward? Reliable and friendly? Stodgy and out-of-touch? Your pharmacy evokes general thoughts and feelings in every patient. Often, they don’t know exactly why. The why is your brand. The image you create through your communications, operations and activities makes up your brand. It forms how patients perceive your pharmacy. And, it plays a big role in their decision to stay loyal to your business. Many independent community pharmacies don’t think about branding. “They often stop once a logo or a logo and tagline have been developed,” said Tom Boyer, director of national accounts and member of the owners group at Hamacher Resource Group (HRG), a firm that improves results across the retail supply chain by addressing dynamic needs such as assortment planning and placement, retail execution strategy, fixture coordination, item database management, brand marketing, and analytics. In a market saturated with national chain and big


ELEMENTS | pbahealth.com/elements

Branding Mistakes to Avoid

Don’t fall victim to these common branding mistakes pharmacies make. • Not creating a brand at all • Creating a brand but not communicating it • Establishing a brand but not supporting it in business decisions • Not communicating the brand consistently

box pharmacies that have deep pockets and prolific marketing, your pharmacy needs to set itself apart with branding. “Branding is important for all businesses,” said Megan Moyer, senior marketing communications specialist at HRG. “It establishes the personality and tone for the business. And it differentiates the pharmacy from the competition.” Branding helps patients understand your business, how it fits their needs, and what to expect when they experience and interact with your pharmacy, Moyer said. And if patients connect to your brand, they’ll remain loyal and tell others about your pharmacy. BRANDING YOUR PHARMACY So, how do you establish your pharmacy’s brand? Start with self-reflection to figure out your pharmacy’s


identity. “What do you want the pharmacy to be known for?” Moyer said. “You have to figure out what you want your pharmacy to be to your customers and within your community.” And this identity doesn’t only mean what you want to present to the public. Think of it as the core of what your business is. “It’s a promise, a commitment to what you want your business to be,” Boyer said. “Pharmacy owners have to believe in the promise of the brand and commit to it.” FINDING YOUR MISSION Your pharmacy’s mission statement should help define your brand identity. Without a mission statement, you can’t have an effective brand. “It sets the standard for what your pharmacy is and what you want it to be in the community,” Moyer said. “Your branding follows that and showcases what you’re about. A mission statement gives you the groundwork for every decision after that.” Developing your pharmacy’s mission and brand takes time and effort. Moyer suggests involving your staff, asking patients for their perspectives and talking to the health care community. BEYOND THE LOGO The heart of your pharmacy’s branding, Boyer said, starts with differentiating your operations. “Branding aims to establish a significant and differentiated presence in the market that attracts and retains loyal customers,” he said. That means your brand needs to encompass more than a catchy tagline or a compelling logo. You may have the greatest logo in the world, but if you don’t offer unique services and products that meet

your patients’ needs, your brand won’t succeed. “What’s behind the logo gets to the heart of branding,” Boyer said. “What you offer that’s different from your competition is what makes people come to your pharmacy.” Boyer suggests pharmacies answer three questions to establish a significant and differentiated presence in the market. First, how can you attract more consumers to your pharmacy? Second, once they’re in your pharmacy how can you get them to buy more? And finally, why do some consumers not come to or buy products from your pharmacy? Equipped with the answers to those three questions, you can figure out what sets your pharmacy apart and how to build a brand patients will connect with. If you want to make your brand last, get your staff involved. Your staff should understand your pharmacy’s mission and your brand, Boyer said. Involve everyone working in your pharmacy, including pharmacy technicians, front-end staff and delivery drivers. If they feel included in the brand development, they’ll be more dedicated to ensuring they represent the brand in their customer interactions and as they carry out their duties. MEASURING SUCCESS After you’ve differentiated your business and established your brand, how do you know your branding is working? “Word-of-mouth is the ultimate measurement of success,” Moyer said. “It means your brand has permeated and you’ve succeeded at getting across what you wanted from your branding efforts.” Word-of-mouth is hard to measure. Boyer said you can find out what patients say about your pharmacy through physician outreach, comments on social media, speaking with patients and listening at community events. You can also use sales to measure success. Have

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your sales increased since you started branding? Are you expanding your products and services to keep up with demand? Don’t worry if your pharmacy doesn’t immediately meet your brand aspirations. For example, you may aim to be a full service pharmacy that includes home health

Anatomy of a Pharmacy Brand

Your independent pharmacy’s name and logo matter. But they make up only a small part of branding. Incorporate all these elements to create a complete brand for your business. Positioning Your pharmacy’s unique position in the marketplace forms the foundation of your brand. What do you offer that nobody else does? When determining your positioning, look to your patients. What do you deliver to your patients every day? Why do they continue to come back? “Become that go-to health care destination,” said Tom Boyer, director of national accounts at Hamacher Resource Group. “Be the knowledge bank where people go. Independent pharmacies shine over their national chain competition when they offer those types of services.” Activities Don’t overlook how activities, like events and outreach, build your brand. Take part in the community by hosting, attending and sponsoring events that support your brand. For example, a pharmacy that sets its brand as health and wellness should host workshops or educational sessions to help patients improve health and wellness. Retail Products Your front-end product assortment reflects your brand. For example, a pharmacy branding itself as the community homeopathic pharmacy with natural remedies for every ailment should stock a


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care products, but you may not have all the resources in place to make that happen right away. “Pharmacies shouldn’t be afraid to set what they may think of as ‘lofty’ brand goals,” Moyer said. “As long as they’re building their business to reach that goal, it’s okay if it isn’t exactly where they want it to be when they establish the brand.”

large selection of natural products. “Make sure you focus on over-the-counter (OTC) or wellness-related products that complement the prescriptions you fill,” Boyer said. Communications Your communications need a consistent message with a unique voice that reflects your brand’s core values. And, messaging means more than marketing and social media. The signs in the pharmacy, the words on your prescription bags and your advertisements all need to reflect your branding. Appearance Your brick-and-mortar building should also reflect your brand. If it doesn’t, you need to update. “If your store looks and feels the same as it did 25 years ago, then you aren’t preserving your brand,” Boyer said. Identity Anything visual that represents your pharmacy makes up your identity. Make your brand identity consistent. Ensure it leaves patients with a good impression. Your identity can include your logo, marketing materials, letterhead, products, signage, uniforms and more. Logo A logo is an icon or mark that identifies your pharmacy brand in its simplest form. It symbolizes the business as a whole. Strategy Support your pharmacy brand with a strategy. Because brands evolve over time, brands that recognize market changes and patient trends will stay relevant.

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Depression Screenings One study reveals how paying pharmacists for mental health screenings can save lives

Sixteen million American adults suffer from depression. That number grows by 20 percent every year and it doesn’t account for the cases that go undiagnosed. That’s one reason the United States Preventative Services Task Force (USPSTF) recently issued an official recommendation to screen every adult for depression. But screening every adult is easier said than done. For one, depression is a sensitive subject. “It has this horrible stigma associated with it, so we never talk about it,” said Jake Galdo, Pharm.D., BCPS, BCGP, assistant professor and director of the community pharmacy residency program at the McWhorter School of Pharmacy at Samford University in Birmingham, Ala. Independent pharmacists are in a perfect position to talk with patients about mental health. They can serve as a source of information on topics patients may feel reluctant to bring up with other providers. “We’re one


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of the most trusted providers and patients see us on a regular basis,” Galdo said. “Patients feel comfortable talking to us and we’re there to help out.” Pharmacists not only make it easier for patients to share their worries, they also provide easier access to mental health care. The average patient will visit an independent community pharmacy an average of 43 times a year, Galdo said. “We’re the most accessible health care provider.” So why don’t more pharmacies offer depression screenings? Galdo said more pharmacies would offer screenings if they got paid for them. He and his colleagues at the Samford University McWhorter School of Pharmacy conducted a study to see if payment makes pharmacies more willing and able to provide mental health screenings. “We knew cognitively that any pharmacist could do this


service,” Galdo said. “So, the question was if we paid a pharmacist, do we get better results?” The study, funded through a grant from the Community Pharmacy Foundation (CPF), provided revealing insights. A LOOK AT THE STUDY Ten pharmacies received a Depression Screening In Pharmacies (DSIP) toolkit that included scripts, workflow, algorithms, and forms that pharmacists could use to implement the screenings. They used the standard two-question Patient Health Questionnaire 2 (PHQ-2) survey for initial evaluation. If patients tested positive on the PHQ-2, they then took the PHQ-9, a nine-question survey that ends with, “Thoughts that you would be better off dead or hurting yourself in some way.” Pharmacy staff offered the service once a week as a one-time event. If a patient tested positive, the pharmacy linked them to care within seven to 10 days. Five randomly selected pharmacies received a $15 reimbursement per screening. The other five pharmacies didn’t receive any payments for the screenings. The researchers compared the two groups for the number of patients screened, average cost to administer the service, and patient-centered outcomes. After six months, the pharmacies that didn’t get paid didn’t offer any screenings. But, sixty percent of the pharmacies paid for the screenings did offer the screenings. From the results, Galdo concluded, “If you pay a pharmacist to do a screening, they’re going to do more of it and help more patients.” THE UPSHOT The study provides evidence for the importance of reimbursing pharmacists for offering depression screenings. “Now we have literature that says if you pay us, we’ll be able to do it. We connect patients to care and we save lives,” Galdo said.

Watch It

Hear firsthand from a pharmacist about how providing depression screenings helped change a patient’s life. As part of the study, “Impact of Depression Screenings in Community Pharmacies,” by the Samford University McWhorter School of Pharmacy, researchers created a video testimonial of a pharmacist explaining how a patient he had known for 15 years had suicidal thoughts and received help. All because of a pharmacy depression screening. Watch the video on YouTube at bit.ly/ pharmacydepression.

A payment model for this service would work best when pharmacists attain provider status, Galdo said. Within that system, pharmacists could bill payers directly for the service using the depression CTT code and get reimbursed the $17.36. “The pharmacist could put up a sign that says, ‘We offer depression screening.’ And you could provide the screening for any patient that walks into the pharmacy,” he said. If pharmacists can do that, patient outcomes will improve. And patients will have an accessible place to go that they can trust. “Pharmacists, particularly independent community pharmacists, can have a real impact on becoming a mental health haven for patients,” Galdo said. Read more and access the materials used in the study at bit.ly/impactofdepressionscreenings.

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Collaborative Care How collaborative practice agreements make patient care more efficient and accessible


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When pharmacists and providers work together, patients and health care are better off. “Collaborative partnerships between pharmacists and physicians empower team-based care, which has been proven to result in better quality care and health outcomes for patients,” said Anne Burns, R.Ph., vice president, professional affairs at the American Pharmacists Association (APhA). Even though evidence demonstrates that pharmacists’ involvement in patient care helps alleviate demands on the health care system and improves patient outcomes, federal and state laws still restrict pharmacists’ capabilities. Collaborative practice agreements (CPAs) help solve that problem. A CPA is a legal agreement between a pharmacist and a prescriber. It defines certain patient care functions—like prescribing or modifying drug therapy—delegated to the pharmacist and the circumstances when the pharmacist can provide them. Pharmacists and providers can—and should— collaborate even without a CPA, but the agreement delegates patient care functions to pharmacists beyond the pharmacist’s typical scope of practice. And those additional functions result in better quality care and patient outcomes. Pharmacists’ unique medication expertise and accessibility complements the services of other healthcare professionals. This collaboration improves the efficiency and reduces the fragmentation of patient care. “When used to their full potential, CPAs have the ability to increase access to care, expand available services to patients and increase the efficiency and coordination of care,” said Jeff Durthaler, pharmacist consultant in the Division for Heart Disease and Stroke Prevention with the U.S. Centers for Disease Control and Prevention (CDC). CPAs are especially beneficial to patients when it comes to chronic disease management. Often, physicians are resource- and time-strained and can’t fully provide the care each chronic patient needs. Pharmacists can fill that gap with accessible front-line

care and medication management. “CPAs can increase patient access to health care by empowering pharmacists to practice as an extension of other healthcare professionals to help patients manage or prevent chronic diseases,” Durthaler said. HOW CPAS WORK CPAs give pharmacists greater autonomy. The legal agreement enables the pharmacist, under specified conditions, to directly adjust patients’ medication regimens to optimize outcomes without constantly consulting the physician for approval. For example, if pharmacists want to modify patients’ drug therapy, they typically have to get permission from the physician. Phone calls, faxes and emails about prescription drug therapy normally occur at least nine times a day in a pharmacy. Under a CPA, the physician may grant the pharmacist authority to make those modifications without seeking permission each time. That cuts out the time-consuming back-and-forth between pharmacists and physicians. And it increases the efficiency of care. “When the pharmacist and physician work together for a long time and the physician trusts the pharmacist’s judgment, those phone calls or faxes back and forth can become an administrative burden that no longer serve a supervisory role,” said Krystalyn Weaver, Pharm.D., vice president of policy and operations at the National Alliance of State Pharmacy Associations (NASPA). “The agreement can say the pharmacist can adjust insulin doses or add on therapy they need. So those administrative burdens of communication back and forth can be reduced.” TYPES OF CPAS There’s no fill-in-the-blank standard for a CPA. But the agreement may specify the patients, the disease states and the medications included in the CPA. Some commonly delegated functions include authorizing refills, adjusting doses, initiating new therapy and ordering laboratory tests.

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Knowing the Variables

Each state’s restrictions and requirements for collaborative practice agreements (CPAs) vary widely. These CPA variables change by state. Authorized Functions • Conduct physical assessment • Discontinue medication therapy • Initiate medication therapy • Interpret laboratory studies • Modify medication therapy • Order laboratory studies • Perform laboratory tests Participants • Number of patients • Number of pharmacists • Number of prescribers • Pharmacist-to-prescriber ratio • Relationship between patient and prescriber • Types of prescribers Requirements and Restrictions • Agreements approved or reported, and to which entity • Communications • Continuing education • Disease state of patient • Documentation • Involvement of patient • Length of time that agreement is valid • Liability insurance • Medications to be managed • Practice setting • Qualifications of pharmacist • Review by physician Source: Centers for Disease Control and Prevention


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Depending on what each state allows, physicians and pharmacists can develop CPAs tailored to meet the community’s needs. “Each physician-pharmacist collaboration is different,” Burns said. “Identifying the most effective functions will be driven by the needs of the physician practice as well as the individual needs of a patient.” Green Line Apothecary, an independent community pharmacy in Wakefield, R.I., entered into a CPA to help the local community suffering from crises levels of Lyme disease. In partnership with a physician at the local hospital through the University of Rhode Island, the CPA enables Green Line Apothecary to provide emergency prophylactic to patients with Lyme disease. Under the CPA, owner and pharmacist Christina Procaccianti, Pharm.D., can dispense two 100mg capsules of doxycycline as a preventive measure for patients who meet specific criteria. “With timing being such an issue here, to be able to walk into a pharmacy and get that kind of level of service can be life-changing,” she said. The Lyme disease CPA demonstrates how specific the terms of a CPA can get, depending on the particular partnership’s needs. Procaccianti’s CPA isn’t a catchall approval for administering doxycycline when she thinks it’s appropriate. Rather, she must evaluate patients according to detailed criteria outlined in the agreement. For example, the patient must bring in the tick or a photograph of the tick for Procaccianti to identify as a deer tick. And patients must have received the tick bite within the last 72 hours, among several other criteria. CPAs are also subject to the requirements and restrictions of each state, including which types of practitioners can participate in these agreements, what the agreements must specifically contain, and the length of time agreements remain valid. Functions that pharmacists can legally perform in one state may not be legal in another.

FIND THE BUSINESS BENEFITS Numerous factors affect the profitability of direct patient care services for a pharmacy. The most important is whether the service is reimbursable or not. Weaver said the primary business benefit of a CPA for pharmacies already delivering direct patient care services is increased efficiency. More efficiency means more business. “You can deliver services quicker, easier, and see more patients if you’re already delivering that type of care,” she said. That’s good for revenue and patient retention. In states that allow it, CPAs can also diversify your revenue streams by adding services in acute and preventative care you otherwise couldn’t offer. For example, a CPA could enable you to prescribe antiviral products to patients who test positive on a rapid diagnostic flu test. “That would be a whole new service that pharmacists could implement in their pharmacy,” Weaver said. “Sometimes patients will pay cash for the convenience, so some of the reimbursement problems with insurance can be sidestepped in that way.” And, your pharmacy can acquire additional patients through a CPA. “Developing collaborative relationships with physicians and other providers in the community can assist in potential referrals to the pharmacy,” Burns said. After all, the partnering physician will refer patients with the appropriate needs to your pharmacy. That boost in traffic can increase sales for that specific treatment but it may also give you an opportunity to turn those patients into long-term, loyal customers. But Procaccianti of Green Line Apothecary cautioned pharmacy owners against jumping into a CPA just to cash in. As long as pharmacists aren’t considered providers and don’t get paid for their time, not all CPAs will benefit a pharmacy financially. Because Procaccianti can’t charge patients for the 10 or more minutes she spends evaluating them for Lyme disease, for example, she doesn’t get paid if they don’t pass the criteria and buy a prescription. “You need to go into it cautiously and because you believe in it,” she said. “Not solely because you think it’s a good business decision.”

Procaccianti also has CPAs for immunizations and naloxone. She said those CPAs bring in more consistent profit due to fairer reimbursement rates. CPAs also help pharmacy businesses adapt to evolving payer preferences because they position pharmacists as providers. Trends identified in the 2017 NCPA Digest, an annual publication from the National Community Pharmacists Association (NCPA) that profiles the $79.8 billion independent community pharmacy market, point to quality of care and patient outcomes as growing drivers for reimbursements, both of which CPAs improve. “Payment models for healthcare services are quickly changing to value-based, risk-sharing payment models where reimbursement is based on outcomes and performance measures,” Durthaler said. “For sustainability, pharmacy practice can evolve to being patient-centered and outcomes-focused.” DEVELOPING AN AGREEMENT The first step to develop a CPA is to find a provider to partner with. Procaccianti recommended choosing a partner based on the patients or conditions you care

The Many Names of a CPA

Collaborative practice agreements (CPAs) go by many different names. Here are some of them. • Collaborative care agreement • Collaborative pharmacy practice agreement • Consult agreement • Delegation of authority by physician • Physician-pharmacist agreement • Standing order or protocol

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Common Services

Pharmacists can provide these common services authorized under collaborative practice agreements (CPAs), depending on the state’s laws and regulations. Authorization of refills The prescriber authorizes the pharmacist to extend refills based on the pharmacist’s assessment of the patient. Without a CPA, in most states, pharmacists would need to contact the prescriber to obtain authorization for a refill. Chronic disease management The prescriber authorizes the pharmacist to initiate, modify or discontinue medications. Laboratory tests The CPA may authorize the pharmacist to order and interpret laboratory tests essential to effectively monitor medications or the status of chronic conditions. Note that some states allow pharmacists to order and interpret laboratory tests without a CPA. Therapeutic interchange The prescriber authorizes the pharmacist to substitute another drug in the same drug class for the medication originally prescribed. Source: Centers for Disease Control and Prevention


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about. “You have to really believe in what you’re doing,” she said. “There’s so much value in that.” Then you build a relationship with the provider, which can organically bloom into a CPA. “The first interaction between a pharmacist and physician isn’t sitting down and writing a CPA,” Weaver said. “Trust develops over time.” That means you don’t jump in with both feet. Instead, you build trust one small step at a time. “Trust usually begins with several routine interactions between prescribers and pharmacists,” Durthaler said. “The best way to create an effective CPA is to engage in offering a basic service with the intent to demonstrate success, build trust, and work collaboratively before a CPA is started.” Start by offering a simple service, like refill authorizations, to show the prescriber your chops. Once they trust you with that service, add in another service. In its toolkit, “Advancing Team-Based Care Through Collaborative Practice Agreements,” the CDC gives an example of what this relationship building could look like in practice. A pharmacist dispenses a prescriber’s prescription and then makes a recommendation. Next, the prescriber accepts the pharmacist’s recommendation for medication therapy. Then, the prescriber delegates disease management responsibilities and grants authority for medication therapy management through a formal CPA. CONVINCING THE PROVIDER Before you can establish trust with a basic service though, you’ll need to meet the provider to convince him or her of the new collaboration. “The pharmacist should be prepared to make the case for the value of formalizing the relationship,” Durthaler said. For the best chance of success, focus on unmet patient needs in the prescriber’s practice and in the community. Choose ones you’re most suited to meet. “Discuss areas of potential collaboration as well as needs of the physician practice that the pharmacist may be able to assist in addressing,” Burns said. Come prepared to answer any of the provider’s questions. “Address the common concerns of prescribers, such as the pharmacist’s level of training and experience in delivering patient care services, communication between the pharmacist and prescriber,

and potential costs incurred as a result of the collaboration,” Durthaler said. Lastly, the potential of greater liability could make providers hesitant to enter into a legal agreement. “The collaborating prescriber would be increasing his or her own liability by entering into a CPA,” Durthaler said. “Let the prescriber ask questions, voice concerns and help to shape the scope of the CPA.” DRAFTING THE CPA Once the partners agree to formalize their collaboration, it’s time to create the legal agreement. “It’s a pretty onerous undertaking because pharmacists and physicians aren’t trained to write legal contracts,” Weaver said. “But there are some resources that can help.” Among the sources Weaver suggests is the CDC toolkit, which provides templates and language to help pharmacies draft a CPA. It also lists the possible steps involved, depending on the state. These include registering the CPA with the board of pharmacy or some other governing body, developing data sharing and business associate agreements, obtaining a pharmacist National Provider Identifier number, and identifying a business model that sustains the scope of services. Even though you develop the agreement with the provider, define the details of each CPA agreement separately. Draft each agreement based on your particular relationship with the provider and use the specific needs of your patients to guide you. “Each physician-pharmacist collaboration is different and identifying the most effective functions will be driven by the needs of the physician practice as well as the individual needs of a patient,” Burns said. CPAs should have some fluidity. If you both discover over time that certain functions or terms aren’t adequately meeting patients’ needs, or if you need to adapt them to changes, you’ll want to have the ability to modify the CPA. Because many collaborative relationships evolve as trust grows, the CPA needs to develop and evolve along with it. State laws and rules will govern the terms of every CPA to some extent, whether by the national board of pharmacy or another governing body. According to the CDC, state laws may limit the types of practices, health conditions or settings in which the pharmacist can perform delegated services.

OUTLOOK OF PHARMACY CPAs are a relatively new opportunity in some states, so their growth and effect on independent community pharmacies may evolve. But Procaccianti said she thinks this is only the beginning. “CPAs are here to stay and regardless of what other people think, pharmacists are providers,” she said. “We should be expanding our capabilities as pharmacists.” CPAs tap into the strengths of independent community pharmacies, like their accessibility and close relationships with patients, to mitigate gaps in care. That makes independent community pharmacies and CPAs a perfect fit now—and in the future. “Nobody is a better resource than your independent pharmacist,” Procaccianti said. “We’re providing a superior level of customer service.” And in Procaccianti’s experience, healthcare professionals are on board. They’re seeing the benefits of CPAs both to help reduce their burdens and to improve health care in general. “The local emergency departments in particular have praised our project,” she said. “They and the local doctors have been very supportive. Something that can be handled in the pharmacy in 10 minutes saves time and money for everybody.” The major obstacle holding independent community pharmacies back is their official status. If the law doesn’t recognize them as providers, they can’t be paid for all the services they can perform. “My time is not valued as a pharmacist like a physician’s is,” Procaccianti said. “It’s frustrating as a retail pharmacist because I’m providing this incredible service for patients. Now’s the time for us to mobilize to gain that provider status.” While CPAs are limited by pharmacists’ status, they also bring pharmacists closer to provider status by demonstrating the effectiveness of team-based care. “In coordination with other healthcare professionals, pharmacists are playing a greater role in the delivery of healthcare services,” Durthaler said. “The pharmacist’s role on a patient’s care team continues to expand and the use of CPAs can accelerate this expansion.” So, perhaps CPAs can do more than change your business. They can radically change the industry for good. For a full overview of CPAs, including a toolkit, infographic, overview webinar and links to additional resources, visit NASPA’s website at naspa.us/resource/cpa.

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Pharmacy + Market How one pharmacy found its niche in a thriving downtown community


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An independent community pharmacy in downtown Raleigh, N.C., has found the perfect ingredients for a successful pharmacy. A combination market and pharmacy in a densely populated district has become residents’ favorite one-stop shop for groceries and medication needs. “The market and the pharmacy are providing services and products that are proven to be needed in this area,” said Tony Gurley, R.Ph., co-owner and pharmacist of Glenwood South Pharmacy and Market. He co-owns the business with his wife, Robin Gurley, R.Ph. “That’s definitely our niche. Meeting the needs of a walkable community like this.” Because the business sits in a densely populated area, it offers extended store hours, staying open until 10 p.m. on weeknights and until midnight Friday and Saturday. And, opening on Sunday. “We’re the only place people can walk to get grocery items and produce and sandwiches,” he said. “The people living here really like the walkability of it. It’s becoming a community store.” Glenwood South Pharmacy and Market provides a fullservice pharmacy and a large grocery market. The market section includes a coffee bar, prepackaged sandwiches, salads and soups. It also offers basic grocery items such as fresh produce, dairy, meats, cheeses, paper goods, drinks, wine and beer. Located below a 203-unit apartment building, the 7,500-square-foot pharmacy and market sits within a burgeoning entertainment and residential district in the heart of North Carolina’s capital. “We’re in the middle of a fasting-growing section of the fasting-growing area of the country right now,” Gurley said. The pharmacy opened in September 2016 after Gurley was set to retire from owning pharmacies. “This opportunity came up and I couldn’t refuse it,” he said. Gurley has owned and sold six independent pharmacies since 1984. He and his wife were already living a quarter mile from the space where they opened the pharmacy. So they live in the same neighborhood as the patients they

serve. “I really wanted a business that was a part of the community,” he said. A HARMONIOUS RELATIONSHIP When patients walk into Glenwood South Pharmacy and Market, they'll notice two things right away. First, they’ll see the sprawling grocery options that take up most of the store’s space. Then, the huge pharmacy sign on the left will grab their attention. Because the market drives most of the foot traffic, Gurley wanted the pharmacy sign to stick in shoppers’ minds. That way they’ll remember it when they need a prescription. “The market gets people in the store on a regular basis,” Gurley said. “So we get our share of prescriptions that way.” The store design spurs shoppers to move back-andforth between the pharmacy and the market with no barrier between the two. Typical retail pharmacy items like beauty products, vitamins and supplements, and first aid items blend into the market, blurring the line between the two sides. “Customers can go between the two and we encourage that,” Gurley said. “And, our employees encourage it by helping customers at any part of the store with any products.” This fluid combination helps both sides of the business because it generates traffic from one to the other. Market shoppers discover the pharmacy. And, pharmacy patients discover the market. “We’re beginning to get people to come in now for the pharmacy who don’t realize that we have the market,” Gurley said. “They come into the pharmacy and are surprised to see we have a beer and wine selection and fresh produce. So it works both ways.” HELPING THE COMMUNITY The market also helps Gurley get to know the communities’ needs, which he lists as his number one priority. “It gives us an opportunity to solicit input from the community and to stock items they want us to carry,” he said.

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business in the area that has free parking. So, that’s a big draw.”

One of the biggest draws of the market, especially among the booming millennial population in the area, is a 600-square-foot beer cave filled with a large selection of cold craft beer and wine. They’re the market’s two biggest sellers. The market even offers occasional beer and wine sampling events. The pharmacy also attracts customers with an outdoor patio with seating and free Wi-Fi. “It’s a real draw to get people down here as they’re taking breaks at work,” he said. In addition, a public space in front of the pharmacy hosts public performances, concerts and other events in the evenings. “It’s a very visible and comfortable area for the public and we promote that as much as we can,” Gurley said. And even though the business sits in a walkable area, people love the free covered parking. “Adjacent to our store, we have 20 spaces that are exclusively for our pharmacy and market,” Gurley said. “People who live in the area can zip right in and out. We’re the only other

SETTING THE BUSINESS APART Gurley knows he isn’t the only business in town to offer grocery and pharmacy in the same store. His closest competition is a Harris Teeter supermarket, a Kroger-owned company with nearly 250 stores. “We recognize that people have a choice to go to whichever pharmacy they want to,” Gurley said. “So, we have to make sure to take away all their excuses to not come here.” He does that by differentiating his pharmacy from a typical grocery store pharmacy in several ways. The pharmacy offers vaccines and immunizations including for flu, shingles and pneumonia. And, from the beginning, the pharmacy has partnered with long-term care facilities to provides adherence packaging for the residents. “That’s really been our niche to get the pharmacy off the ground,” Gurley said. “You aren’t going to find these services in a chain pharmacy or a grocery pharmacy combination. It’s more of an independent pharmacy attitude that we brought over to the combination store.” He also prioritizes personal service for his patients. “I place a high value on customers' time,” he said. “When we fill prescriptions, we do it quickly. When the phone rings, we pick it up. We have things ready for patients when we say we will.” The personalized service also includes free prescription delivery anywhere in the county. Homes and businesses within a certain radius of Raleigh receive same-day delivery. Delivery outside that radius but within the county receives next-day delivery. Most importantly, the pharmacy differs from other options because it tailors its products and services to its specific community. “It all boils down to meeting the needs of your market,” Gurley said. “If there was no need for a market, having one with a pharmacy wouldn’t be a benefit. The fact is that people need this. We provide products they told us they wanted us to carry and they come in every day. That helps the pharmacy dramatically.”

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Prescription Logs How to use prescription dispensing logs to better manage your pharmacy business Your prescription dispensing logs can do more for your business than you might expect. “They help you check in on what’s going on behind the bench and how you’re managing the business,” said Scott Sykes, CPA, of Sykes & Company, PA, an accounting firm focused on independent community pharmacies. “It’s a supplemental tool to help break down and provide analysis for how your pharmacy is performing.” You most likely check your logs every day for billing information and dispensing errors. But do you use them to help maximize your margins and track your business growth? Prescription logs give a snapshot of your pharmacy’s


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“They help you check in on what’s going on behind the bench and how you’re managing the business.” prescription operations. When used to their full potential, they reveal surprising insights that can help you manage your pharmacy better. HOW LOGS HELP YOUR BUSINESS Incorporate your monthly prescription audit log into your monthly accounting process. “A good pharmacy CPA compares that monthly audit log with your financial statements,” Sykes said. For example, the CPA compares total sales, third party sales, margins from scripts and new versus refill. At a minimum, prescription log information alerts you to discrepancies. “If there are large differences, it

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raises a flag,” Sykes said. “You’ll see if something’s not quite right in that script issue. Or, you’ll see you have an inventory issue you need to address or a third party receivable issue.” This discrepancy check can help pinpoint major problems. “If margins on the financial statements show a 14 percent gross margin but the script logs show 20 percent, you need to ask what’s going on there,” Sykes said. Prescription logs also reveal missed opportunities and areas for improvement. In particular, Sykes said to use the logs to review your margins. “If your margins on your audit log are 12 percent, for example, then either you’re not buying well or you’re not getting the most out of what you’re submitting and adjudicating,” Sykes said. “Maybe you have opportunities to increase that margin per script.” Sykes & Company uses script log information to monitor gross margin for its pharmacy clients. At the end of each month, the firm compares the adjudicated amount and the margin amount against the perpetual inventory system and the actual costs of goods sold. The firm uses it as a test for what the gross margins should be on the profit and loss statement. And that information is paramount to any pharmacy’s success. “The most important thing for a pharmacy is how well they buy,” Sykes said. “If their margins are off, you can see that through these reports.” MONITORING BUSINESS GROWTH Prescription logs also help monitor the growth of your business. The ratio of your new scripts versus refills indicates whether your pharmacy is trending up or down. If your percentage of new scripts is lower than your percentage of refills, that signals a lack of growth. That single piece of information reveals the need to attract more new patients or risk going out of business in the future. Sykes said prescription logs can help pharmacies better understand their acquisition costs. Issues commonly crop up with acquisition cost data, particularly when pharmacies purchase from multiple secondary suppliers. “Perhaps the daily feed from the main wholesaler is overriding other prices if you’re buying a lot from other suppliers,” he said. To check that, your pharmacy can download the acquisition cost sheet from the wholesaler and compare it to the recorded acquisition costs in the script log. To prevent it, consistently compare the cost sheet and


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What to Look For

Your pharmacy management system provides summaries that contain a gold mine of data on your pharmacy’s performance. Use your prescription logs to check: • • • • • • • • • •

Acquisition costs Adjudications Average compounding margin Average markup on cash scripts New prescription fills Refills Third party scripts Total cash scripts Total margin Total scripts

script log and keep the system up-to-date with accurate acquisition costs. INVEST TIME IN YOUR LOGS Check your prescription logs daily, monthly and annually, Sykes said. Prevent extra burden on busy pharmacy owners by delegating the duties to a qualified tech or pharmacist. “Experienced pharmacists and techs can identify discrepancies or errors right off the bat,” Sykes said. “It shouldn’t take long if they’re doing it every day.” And, Sykes emphasized that prescription logs can’t replace financial reports. “What you adjudicate behind the bench isn’t what you’re going to receive,” Sykes said. “You shouldn’t use these to record any accounting or revenues or adjustments. They’re supplemental.” If your pharmacy hires a CPA to do its accounting, make sure your CPA understands the benefits of prescription logs. Not every CPA knows how to use prescription logs in this way, especially if they don’t specialize in independent pharmacy. “In today’s environment, you can find an industry-specific CPA like our firm that can work anywhere,” Sykes said. “Finding one that fits your needs can certainly add value.”


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Trend Spotting

A look at the most important independent pharmacy trends for 2018 As industry trends change, independent community pharmacies need to watch and evolve to stay successful. The 2017 NCPA Digest, an annual publication from the National Community Pharmacists Association (NCPA) that profiles the $79.8 billion independent community pharmacy market, reveals some troubling and promising trends. And these trends can affect your pharmacy business in big ways in the coming year. TROUBLING TRENDS Reimbursements continue to shrink. Exclusionary networks keep expanding. DIR fees are swelling to unprecedented proportions. Those factors drive down prescription sales and force pharmacies to evolve and expand beyond dispensing. “Pharmacies must consider alternative revenue sources,” said John Norton, director of public

relations at NCPA. “They must identify a range of services available to pharmacy owners that can both meet important health and consumer demands while also boosting the bottom line.” Although pharmacies have long dealt with belowcost reimbursements, Norton said DIR fees are shaking up the industry beyond expectation. “The explosion of DIR fees over the past couple of years has been so dramatic that it has overtaken other issues, such as generic prescription drug reimbursement and preferred pharmacy networks in Medicare Part D, as the top concern of our members,” he said. Even so, preferred networks still strain independent community pharmacies. “Continued expansion of preferred networks created by PBMs make it difficult for independents to compete for patients in the Medicare Part D program,” Norton said. More than half of independent pharmacy prescriptions come from Medicare and Medicaid, which can mean a large chunk of lost business for many independent pharmacies. These negative trends have resulted in independent pharmacy profit margins dropping each year for the last three years. The total number of independent pharmacies and the total amount of prescriptions filled have fallen since 2015.

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“These numbers sound a cautionary note,” Norton said. “Independent community pharmacy owners can’t afford to be complacent.” PROMISING TRENDS IN THE COMING YEAR “Despite a challenging marketplace, independent community pharmacy owners are finding ways to expand,” Norton said. Between 2014 and 2016, the number of stores owned by a community pharmacy owner rose from 1.69 to 1.96. And, 29 percent of independent community pharmacy owners had ownership in two or more pharmacies in 2016, up from 27 percent in 2015. Independent pharmacies find success by offering more niche services to counteract DIR fees and belowcost reimbursements. “The rapid implementation of med sync, collaborative agreements, and alternative value-based care are allowing pharmacies to innovate and adapt to a changing environment,” Norton said. Medication synchronization programs nearly doubled in the last three years. About 80 percent of independent pharmacies offer them. Medication synchronization helps boost the bottom line, Norton said, by reducing operating expenses, increasing script count and increasing adherence. Collaborative agreements have grown as health care providers continue to gain trust in pharmacists. Providers in 2016 accepted 95 percent of pharmacists’ brand-to-generic drug recommendations and 80 percent of drug therapy changes. This growing trust has resulted in a 4 percent rise in collaborative care agreements since 2015. TRENDING FOR THE FUTURE If pharmacies want to survive, they need to evolve beyond simply dispensing prescriptions. Payment models have already shifted focus to value, quality, and outcomes. “They’re causing all health care providers to relook at what they are doing, how they are doing it, and who they are doing it with,” Norton said. “This leads to new collaborations, new ways of working together across health care professions, and new revenue models.”


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By the Numbers

Here’s a breakdown of the niche services independent community pharmacies provide to diversify their services today. 92 percent - Medication adherence/ synchronization 87 percent - Medication therapy management 76 percent - Immunizations 72 percent - Home or worksite delivery 62 percent - Blood pressure monitoring 63 percent - Compliance packaging 44 percent - Hospice 44 percent - Long-term care Source: 2017 NCPA Digest

NCPA is encouraging pharmacies to get involved with a Community Pharmacy Enhanced Services Network (CPESN). “They link pharmacies that provide enhanced services into a network of community pharmacies that can assist payers in improving patient health and reducing overall health care spend, especially for patients with the greatest care needs,” Norton said. And because independent pharmacy growth depends on government legislation, getting involved matters. A lack of third-party regulation keeps PBMs in power. And restrictions hold pharmacies back. “Independent community pharmacists must find time to advocate for the pharmacy-friendly policies at the federal and state level,” Norton said. Independent pharmacies today can’t abide by the status quo. “It’s important for independents to diversify their product line to include services beyond traditional dispensing of prescriptions,” Norton said.

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Biodegradable Vials How one pharmacy is making prescription dispensing more environmentally friendly Most patients throw away everything they receive from a pharmacy. From the paper bag holding the prescription to the vial housing their medication. One pharmacy is trying to make the business of filling prescriptions more earth-friendly. One prescription vial at a time. Since March 2017, Rivergate Pharmacy & Compounding Center, an independent community pharmacy located in Durango, Colo., has dispensed prescriptions in biodegradable vials. “Our patients love them. We even have new customers who transferred in because of these vials,” said Lori Kearney, R.Ph., owner and pharmacy manager of Rivergate Pharmacy. EARTH-FRIENDLY CONTAINERS The pharmacy purchases the biodegradable prescription vials from Pharmacy-Lite Prescription Packaging, a manufacturer of vials and packaging for pharmacies. “Traditional prescription vials are not designed to biodegrade,” Kearney said. The non-toxic and BPA-free plastic vials contain an organic biodegrading additive called ENSO. Kearney learned about the science behind the vials from a representative with Pharmacy-Lite Prescription Packaging. “These plastics have been designed for their physical properties, strength and durability,” Kearney said. “Most plastics contain primarily carbon atoms linked into long chains. Although carbon is a great nutrient source for microorganisms, the long chains make it difficult for microorganisms to metabolize them. Biodegradation of


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these plastics can be accelerated through the use of the ENSO technology.” FINDING WAYS TO GO GREEN Kearney originally saw the vials at a pharmacy conference, but didn’t think the pharmacy could afford them. “I saw them again at the beginning of this year and started asking questions,” she said. “When I realized we were looking at pennies difference and not hundreds of dollars, I ordered some and took it back to our team to get their input. They loved them.” And patients did too. “We’ve had a lot of positive feedback in the pharmacy as well as on social media,” she said. The pharmacy also tries to keep the environment in mind every day. Recycling bins in the pharmacy include paper, plastics, glass and cardboard. “We recycle whenever we can,” Kearney said.


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Elements Magazine - Vol.6 Iss.4 Dec 2017  

Elements Magazine - Vol.6 Iss.4 Dec 2017  

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