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ELEMENTS

MAKE IT TWO Independent pharmacies and patients can profit from vaccine co-administration

SIMPLIFYING WELLNESS How one company is changing the supplement landscape for pharmacies

The Compounding Effect Grow your business by returning to pharmacy’s roots

VOL. 6 ISS. 3 | SEPT 2017 | 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 Paige Fisher – Graphic Designer Torrie Wright – Contributing Writer Greyson Honaker – Contributing Writer INTERESTED IN ADVERTISING? elements@pbahealth.com

Contents Departments 20 SPOTLIGHT:

5 NEWS:

A Collaborative Partnership How pharmacists can work alongside physicians to improve patient health. 6 TRENDS:

Locked Up Locking prescription vials aim to stop opioid addiction before it begins. 8 RETAIL:

In Any Event Tips to prepare your pharmacy for an in-store event. 12 SOLUTIONS:

Make It Two Independent pharmacies—and patients—can profit from vaccine coadministration.

ON THE WEB //

Increasing Efficiency How one independent pharmacy owner works smarter by improving workflow. 24 MONEY:

Equipment Leasing See how Live Oak Bank helps independent pharmacies with equipment financing. 29 OUTLOOK:

Simplifying Wellness How one company is changing the supplement landscape for pharmacies. 34 NOTES:

Spread the Word Get ready to successfully market your pharmacy’s flu shots this season.

Feature: The Compounding Effect

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Grow your business by returning to pharmacy’s roots.

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

Is Your Pharmacy’s Customer Service Really the Best?

You probably think your pharmacy’s customer service is the best in the business. But how can you be sure? Follow these tips to differentiate your pharmacy. Read more at pbahealth.com/ pharmacys-customer-service-really-best.

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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NEWS

A Collaborative Partnership How pharmacists can work alongside physicians to improve patient health As pharmacists’ role in health care continues to expand, the American Medical Association (AMA) is paying attention. As a part of its STEPS Forward™ initiative to help physicians improve their practices, the AMA recently created an educational module that explains how physicians can build collaborative relationships with pharmacists to more effectively manage patient care. “It’s important for physicians to integrate pharmacists onto their team,” said Hae Mi Choe, Pharm.D., one of the module’s authors and an associate dean and director of pharmacy innovations & partnerships for the University of Michigan College of Pharmacy and the University of Michigan Medical Group, respectively. “There’s a growing need for pharmacists in managing our complex, chronically ill patients.” With people living longer, physicians must manage more chronic conditions, which come with more complicated medication regimens and more problems with adherence, interactions and polypharmacy. “Together, physicians and pharmacists can develop protocols to optimize drug therapy to achieve clinical outcomes,” Choe said. In addition to a growing number of patients with chronic conditions, physicians are being held to increasingly higher standards of care, Choe said. And they can best meet those standards with help from experts in medication management. “How you meet that need is by introducing pharmacists that can work in concert with physicians in terms of improving chronic disease management or doing comprehensive medication reviews for patients with complex medication regimens,” she said.

pharmacy fits into that model because currently they operate in separate spaces,” Choe said. “And their two spaces don’t always have a good communication path, even with simple things like a patient needing a refill.” Sharing patients’ basic health information is an effective way physicians and pharmacists can use better communication to improve patient outcomes. “The community pharmacists’ hands are tied,” Choe said. “They don’t have access to medical records; they don’t have direct access or a link to the physicians to make any recommendations or to have a dialogue about the patient.” In the module, Choe recommends physicians tell their patients to share copies of their charts, such as medication lists, visit summaries, lists of medical conditions and basic labs, with their pharmacist. With more information, community pharmacists can make informed decisions to help patients manage and adhere to their medications. But before collaborative partnerships can occur, physicians’ entrenched perspectives need to change. “The first step is for the physician community to recognize there’s a need for a pharmacist with medication expertise,” Choe said. She said embedding pharmacists in physician practices is the most effective method for convincing physicians of that need, which she hopes the STEPS Forward module will help achieve. “Once physicians experience what it’s like to work with the pharmacist and recognize that the pharmacist is a valuable member of the care team, then it’s easier for them to branch out and extend this type of relationship into the community where patients actually live, where they visit the community pharmacy more often.” Check out the module at stepsforward.org/modules/ embedded-pharmacists.

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

BRIDGING THE GAP The first step in a physician and pharmacy partnership is bridging the communication divide between their practices. “The link has to be how the community

information and exclusive offers.

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TRENDS

Locked Up Locking prescription vials aim to stop opioid addiction before it begins If you had a way to help patients prevent family members and friends from pilfering prescription drugs from the family medicine cabinet, you could curb opioid abuse at its source. That’s the idea behind Safe Rx’s locking prescription vials, which store narcotic prescriptions. “No one intentionally wants to have their children or family members get accidentally addicted to narcotic items,” said Anthony Dolan, vice president of pharmacy sales and marketing at Safe Rx. “By keeping controlled medications out of the hands of those who they’re not intended for, we are taking a step toward improving the health of those in our community,” The locking prescription vial’s cap contains a four-

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“America is at a crossroads, and we need to take a more proactive attitude to preventing addiction.”


TRENDS

digit plastic lock that resembles a bike lock and has 10,000 possible combinations. The 18-dram vials are made of pharmaceutical grade plastic and are darker than a typical vial to prevent seeing through to the locking mechanism. If someone without the code tampers with the vial, the owner of the pills will know— either the bottle will shatter or the pins that connect to the cap will be damaged. Many patients don’t think pilfering will happen in their home. But Dolan said everyone should take preventative action, even if they don’t think they’re at risk. “When we drive, we put our seatbelt on. We aren’t planning to get into a wreck,” he said. “No one assumes that someone in their household is going to try to steal some of their narcotic prescriptions but it does happen, and that leads to opioid abuse.” GOOD FOR PHARMACY AND PATIENTS As the dispensing source of prescription opioids, pharmacies play a vital role in the opioid crisis. Dolan said Safe Rx helps pharmacies become a part of the solution. “Safe Rx locking prescription vials allow pharmacists, and pharmacies, to become active participants in preventing inadvertent diversion in the communities they serve,” he said. In addition to helping prevent drug diversion in the community, locking prescription vials can benefit the pharmacy business. “Pharmacies take a supply item and make it a profitable SKU,” Dolan said. “Instead of providing a vial at no retail benefit for the pharmacy, they’re selling a product.” Locking prescription vials retail at around $3 to $4 and all of that money is additional revenue for the pharmacy. Offering locking prescription vials could also generate new customers for pharmacies. In a Safe Rx survey, more than half of parents with teens in the household said they would switch to a pharmacy that dispensed in locking prescription vials. Ultimately, Safe Rx enables your pharmacy to provide a benefit to your patients that goes deeper than their physical health and reaps rewards beyond

A Simple Process

Filling a patient’s prescription with a locking prescription vial takes a few extra seconds of a pharmacist’s time, said Anthony Dolan, vice president of pharmacy sales and marketing at Safe Rx. Here’s how a pharmacist would fill with a locking prescription vial. Step 1: Turn the digits on the cap to the patient’s requested code Step 2: Press the cap onto the encoder Step 3: Place the cap on the vial and hand it to the patient

measurable metrics. “Safe Rx gives patients peace of mind,” Dolan said. “They understand that their medications are safe in the household and that they’re preventing diversion among their family and friends.” LOOKING TO THE FUTURE Safe Rx is currently developing a pre-encoded line of locking prescription vials and is in the process of licensing its technology for use on pill organizers, both of which should be available in 2018. It will also start offering 60dram wide mouth vials this year. “America is at a crossroads, and we need to take a more proactive attitude to preventing addiction,” Dolan said. “There seems to be a new story every week about how opioid addiction has adversely impacted families and communities across our country. The time has come for people to actively protect their loved ones with a locking prescription vial, which costs less than a fancy cup of coffee.” Learn more at safe-rx.com.

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RETAIL

In Any Event How to prepare your pharmacy for an in-store event Have you thought about hosting an event at your independent community pharmacy? Hosting events is an important part of promoting your business, said Dave Wendland, vice president, strategic relations and a member of the owners group at Hamacher Resource Group, 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. Hosting in-store promotional

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How to Market Your Pharmacy’s Event

Spread the word about your pharmacy’s event to the community with these marketing ideas. • Send postcard or email invitations • Create a Facebook event • Use a paid online advertisement • Put banners or signage in front of the store or in store aisles • Leave flyers at neighboring independent businesses • Use bag stuffers in prescription bags • Call your top customers and personally invite them • Call neighboring professionals and invite them • Contact the local media


RETAIL

events can attract new shoppers, reward current customers and introduce new offerings or services. If independent pharmacies don’t focus on promoting their businesses, such as through community events, they run the risk of falling behind. “Independent pharmacies are in the crosshairs of competition,” Wendland said. “On one hand, it’s an enviable position because every national chain today wants to be local and personal, like independent pharmacies. However, the national chains and e-commerce vendors realize there are constraints on a small business operator.” For example, small businesses don’t have the pricing advantages, the assortment variety or the versatile hours of operation that national chain pharmacies do. Instead, independent pharmacies have connections with consumers and their community, which they can enhance through in-store events. “When an independent pharmacy connects with consumers through an event, it can be a game changer for them,” Wendland said. “It reinvigorates the customers, the community and their staff.” PLANNING THE EVENT Wendland said the first step when planning an event is deciding to hold an event. “I’ve seen many independent pharmacies scratch their head and say, ‘Wow, it’d be a great idea to have an event. I wonder if we should.’ And the answer should always be ‘yes.’ Hold an event,” he said. “Once you’ve committed to it and you follow through, you’re going to be energized by it.” After deciding to host an event, you need to select the theme and the date because those factors need to correlate. Then, the planning can begin. Wendland doesn’t recommend pharmacies hire outside help to plan and execute the event. Instead, he suggests first asking for volunteers from among your staff. “The most underused resources that most pharmacists fail to recognize is their own staff and the individual talents they have,” he said. You may have to pay employees overtime or give them a special gift of appreciation, but those tokens are far less expensive than hiring an outside firm. Wendland does recommend pharmacies seek out expertise. For example, Hamacher Resource Group authored an event planning e-book for Upsher-Smith Laboratories, Inc., called “Promotional Event Planning Made Easy.” It covers best practices of event planning

for a pharmacy and provides ideas and examples to attract customers and the community to your store. (Find the e-book at hamacher.com/promotional-eventplanning-made-easy.) Additionally, Wendland said pharmacies need to talk to other pharmacies and organizations and ask questions about the events they’ve held to gain insight on what works and what doesn’t. “Stores talking to stores is still the absolute best source of information,” he said. PARTNERING WITH LOCAL BUSINESSES Cut costs and expand the reach of your event by partnering with other local businesses. “The more businesses a pharmacy can get involved, the more reach they’re going to have,” Wendland said. Partner with a non-competing organization that will complement your business and that can provide additional services or entertainment. For example, look to other area health care professionals or social service agencies in your community. “If you’re doing an eye health event, maybe there’s an optometrist in town that would be willing to do eye testing for you,” Wendland said. Or, if it’s a diabetes event, get in touch with the local chapter of the American Diabetes Association. “Not only do they have literature, oftentimes they have personnel who would be willing to give a talk on a related subject. Or, they might have a means of promoting it to their constituency,” he said. Wendland also recommends partnering with businesses that can enhance the overall experience of the event for your guests, such as a local bakery or a florist. PROMOTING THE EVENT For people to come to an event, they have to know about it. Wendland said the top three ways for pharmacies to promote an in-store event are word-of-mouth, bag stuffers and free publicity. “Get everybody in the store talking about it to their friends and families,” he said. “Make it relevant and make it something the community is buzzing about.” Pharmacies also need to have promotional materials at the event, such as goodie bags and other giveaways. Wendland suggests soliciting free product samples as giveaways. “If you’re doing a diabetes awareness event and you contact a blood glucose manufacturer

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Types of Events

Want to be the life of the party? Here are some pharmacy event ideas to consider. Health awareness event Plan a pharmacy event around national health observances. Examples: American Heart Month, National Nutrition Month, American Diabetes Month, National Influenza Vaccination Week Vaccination event Host a travel vaccination event for people heading out on trips. Examples: Pre-cruise planner, mission trip planner, college trip planner Seasonal event Plan pharmacy events to celebrate different seasons and to sell your seasonal products and services. Examples: Sunny-Side Up, Back-to-School, Winter Solstice Community event Host an event in conjunction with celebrations, activities and holidays in your community. Examples: Sidewalk sale, Founder’s Day, holiday parade

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or a sugar-free candy distributor, chances are they’d be more than willing to support you with some free product as samples to share with your guests,” he said. Pharmacies can also work with their drug wholesaler to create a goodie bag. Or, you can create your own using some of the unique items and private label products in your store, Wendland said. And, aside from giveaways, also make educational materials available for patients related to the theme of the event. MEASURING SUCCESS While many businesses hope to use sales as a measure of success, Wendland said there are too many mitigating factors to base success solely on a sales uptick. “I would look for some other less sales-related goals and be specific about them,” he said. “If one of the pushes within the store is to get people to sign up for a store newsletter, set a goal to get 50 new contacts on your email list as a result of the event.” And, for an independent community pharmacy, Wendland said neighborhood goodwill is an indicator of success. “If patrons get exposed to the operation and walk away with a good feeling, and if they’d like to come back and do business with you, that goodwill is hard to measure but difficult to replace,” he said. Regardless of the event’s success, start planning the next one shortly afterward. “Any event should be a test-and-learn,” Wendland said. “Even if the measurement of success was less than stellar or didn’t reach the goal, you’ll miss the boat if you don’t hold and plan another event.” Additionally, pharmacies should do as much follow-up as possible after the event to ensure its continued success. “If you asked people to enroll in a class and are supposed to let them know when it’s going to be scheduled, be sure to follow up with them,” Wendland said. “The momentum has to keep going. An event is not a flash in the pan. An event is part of a continuum.”


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SOLUTIONS

Make It Two How independent pharmacies and patients can profit from vaccine co-administration Is your pharmacy taking full advantage of immunization services? Justin Wilson, Pharm.D., co-owner of Valu-Med Pharmacy in Midwest City, Okla., said immunizations are one area where pharmacies can still make a healthy profit margin compared to prescription medications. And, physicians are starting to move away from offering immunizations, presenting a big opportunity for independent community pharmacists. “I think more physicians in our community are getting out of the vaccine business,” Wilson said. “They’re not seeing the same profit margins they used to, and some of the storage requirements and inventory issues make it a challenge for them.” Wilson makes the most of his pharmacy’s immunization services by offering vaccine coadministration, where patients receive two or more needed vaccines in one sitting. It’s convenient for patients and profitable for the pharmacy. IMPROVE PATIENT HEALTH Wilson’s main reason for co-administering vaccines is to improve patients’ health. He said the goal is to get all of his patients up-to-date on the recommended vaccine schedules. “We always try to make our business decisions based on what’s best for our patients,” he said. “I saw it as a community need because patients were coming into our stores needing these vaccines and didn’t know where to get them.” Valu-Med Pharmacy especially takes advantage of vaccine co-administration during flu season. When patients come in for flu shots, they fill out an intake form and pharmacists ask about the last time they

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Travel Ready

Vaccine co-administration isn’t just for flu season. Valu-Med Pharmacy in Midwest City, Okla., co-administers travel vaccinations to patients who plan to leave the country. Consider co-administering these travel vaccines at your independent pharmacy to increase profits. • • • • • • • •

Cholera Hepatitis A Hepatitis B Meningitis MMR Polio Shingles Tdap (Tetanus, Diphtheria, Pertussis) • Typhoid • Yellow Fever

received other recommended vaccines. “It allows us to at least start the conversation with the patient,” he said. Simply asking those questions tripled the number of pneumonia shots the pharmacy gave during the last two flu seasons. And because the pharmacy takes the time to determine each patient’s needs, Wilson said getting patients to receive more than one vaccine at once is an easy sell. “As we’re interviewing them and finding out what their needs are, we’ll make those recommendations and if their insurance covers the cost of the vaccine, it’s a no-brainer,” he said. Wilson said most patients get a flu shot every year, so they’re coming to the pharmacy anyway. “The way we market it to patients is you might as well get it all over with in one visit rather than having to come back multiple times,” he said. INCREASE PROFITS Vaccine co-administration is a large profit center for


SOLUTIONS

Valu-Med Pharmacy. “You get reimbursed on the backside for administration fees, so it allows us to keep the doors open a little bit better than if we didn’t have the vaccine service for our pharmacy,” Wilson said. Reduced margins and dwindling reimbursements from insurance companies and third party payers have been a big issue on the prescription side of the business. “If we weren’t providing these vaccines, I think our numbers would look a lot worse,” Wilson said. Co-administering vaccines can even attract new patients. “We’ve had patients come to us from as far as three hours away because they couldn’t find the vaccine in their community, so it brings extra business,” he said. As long as there’s not a compatibility issue or interactions, most vaccines can be coadministered, Wilson said. For example, ValuMed Pharmacy is a travel immunization center, so the pharmacy often co-administers different travel vaccines patients need. Wilson advises other independent community pharmacies considering co-administering vaccines to jump in head first. “Especially if they’re already giving flu shots,” he said. “It’s pretty easy to start offering these other vaccines. You may have a little bit of an inventory back stock to get started with some of the shots but as far as policies and procedures, you’ve already got those in place.”

A Profitable Flu Season

Flu season is a great time for pharmacists to co-administer vaccines to get patients up-to-date with their vaccination schedules. Here are some vaccines you can co-administer to patients when they come in to receive a flu shot. • • • • • •

Hepatitis A Hepatitis B Meningococcal Pneumococcal Tdap (Tetanus, Diphtheria, Pertussis) Zostavax® (Shingles)


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The Compounding Effect Grow your business by returning to pharmacy’s roots

By Greyson Honaker

The mortar and pestle remains the iconic image of pharmacy, but these days a picture of a packaged, manufactured drug might be more fitting. Once the standard pharmacy practice, compounding is now a small portion of pharmacies’ prescription sales, if it’s offered at all. The median percentage of pharmacy sales that come from compounded prescriptions is only 8 percent. And an estimated 75 percent of pharmacies that offer finished dosage medications aren’t providing compounded medications. Many independent pharmacies are missing out on this untapped market that could differentiate their business. “Compounding is an area where pharmacies can grab the bull by the horns,” said John Norton, director of public relations at the National Community Pharmacists Association (NCPA). “Chain competitors aren’t really in that realm or, if they are, it’s to a very small extent.” From a child who can’t swallow a pill to an adult who’s allergic to an ingredient, many patients require medications that drug manufacturers don’t produce. They rely on a pharmacy to create personalized medication for them. “For a lot of folks there aren’t other options or alternatives for them besides using a compounded product,” said Ronna Hauser, vice president of pharmacy affairs at NCPA. This much-needed personalized care makes compounding an excellent business opportunity for your pharmacy. “It can really help their practice because now they’re offering a service that the patient

can’t get anywhere else,” said Donnie Calhoun, CEO of the American College of Apothecaries (ACA) and owner of Calhoun Compounding Pharmacy in Anniston, Ala. It’s the right fit for independent pharmacies. “You can increase your profile, attract more patients and provide more care,” Norton said. “It’s a natural fit if you can find the resources and time.” A PROFIT PRODUCER In a market choked by declining reimbursements, pharmacies need every opportunity to make up for lost margins. Compounding provides one of the better channels for profit. “You’re seeing more existing pharmacies, as they have margin pressure on the front end of their store as well as the finished dosage side of their operation, add compounding as a way to enhance the profitability of their business,” said Doug Bowman, CEO of Letco Medical, a supplier of compounding products and services. “The profitability really helps the overall viability of the pharmacy.” Calhoun, who’s been practicing compounding for decades, experienced the profitable benefits from the moment he started compounding. “I was maybe doing 10 compound prescriptions a day,” he said. “But I would say that those 10 prescriptions would generate enough profit to take up 50 traditional prescriptions. Maybe more.” Rather than paying for a finished product, pharmacies purchase compounding ingredients directly. The compounded medication offers higher

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Guidelines to Know

How well do you know these guidelines? Three chapters from the United States Pharmacopeia (USP) set the primary standards for compounding, which your state board of pharmacy may or may not enforce. USP 797: Standards for Compounding Sterile Preparations Helps to ensure patients receive quality preparations that are free from contaminants and that are consistent in intended identity, strength and potency. It describes a number of requirements, including responsibilities of compounding personnel, training, environmental monitoring, storage and testing of finished preparations. USP 795: Standards for Compounding Quality Non-Sterile Preparations Provides guidance for nonsterile preparations that are compounded in health care settings. It describes categories of compounding (simple, moderate, complex), defines concepts, such as beyond-use date and stability, and provides criteria for compounding pharmacists to follow in preparing various drug preparations. USP General Chapter 800: Safe Handling of Hazardous Drugs Establishes practice and quality standards of hazardous drugs to minimize the exposure to hazardous drugs within health care settings. This standard aims to promote worker safety, patient safety and environmental protection. It will not be officially implemented until July 1, 2018. Source: American Pharmacists Association (APhA) and United States Pharmacopeia Convention

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margins for pharmacies because it requires fewer expenses to provide the product. But Phil Blouch, U.S. outside sales manager at Medisca, a supplier of compounding products and services, said that profitability isn’t a given. “It depends on many factors, such as the suppliers you source from, your operational costs and overhead, the demand and timing of the prescriptions and insurance coverage,” he said. “However, pharmacists who are willing to invest the resources and time required to maintain a compounding pharmacy can see a favorable return in profitability.” THE CASH ADVANTAGE Another reason compounding typically yields more profits than traditional dispensing is cash. Cash payments are more common among compounding pharmacies than traditional dispensing pharmacies. According to an NCPA survey, patients pay for half of compounded prescriptions with cash. Cash payments allow pharmacies to avoid the reduced margins of third-party reimbursements and the pains of reconciliation. “The cash pay model really helps cash flow and delivers gross margin on a stable basis for the business,” Bowman said. At Calhoun’s Compounding Pharmacy, 95 percent of compounded prescriptions are paid for with cash. “Now there’s a way you can capture some of that profit back into your pharmacy,” Calhoun said. The prevalence of cash payments also reflects the coverage instability of compounded prescriptions. Medicare Part D doesn’t cover compounded medications and the coverage from other insurers “varies greatly,” Hauser said. “We have seen over the last few years fewer and fewer compounds that are covered. It’s becoming more the rule that compounds are not covered,” she said. Lack of insurance coverage isn’t typically a deterrent for patients needing a compounded prescription. “People are willing to pay if you can help their child, if you can help their pet, if you can help their mom,” Calhoun said. “They’re willing to pay you for your services if you can show them that what you’re doing is helping them.” Blouch said the appropriate pay model—whether cash or insurance—should vary from pharmacy to pharmacy. “The pharmacist needs to determine which


business model works best for them based on their niche and types of prescriptions they’re filling,” he said. BUILDING REVENUE Beyond profit, compounding adds another element to pharmacies’ offerings. It makes their business a more attractive choice for patients looking to get everything in one place. “It really completes the circle of available services that pharmacies can offer their patients,” Bowman said. “It’s a great complementary offering for patients who are seeking personalized and customized medication, which is on the rise.” Blouch agrees and he added that compounding can also keep customers loyal to your pharmacy. “This service will allow your patients to visit your pharmacy as a ‘one-stop shop,’ preventing them from shopping elsewhere for their custom prescription needs,” he said. And, the patient interaction required for compounded medications creates a unique bond not typically seen with standard retail pharmacies. “This type of relationship is invaluable for long-term client retention,” he said. In combination with other services, like immunizations and medication counseling, compounding adds additional revenue streams for pharmacies. “All of these things can help bring residual income so you’re not just dependent on those third party contracts,” Calhoun said. “My goal for ACA members and for all community pharmacists is to take that PBM portion of your business and to make that smaller and smaller so eventually the PBM business is such a small part of your overall business that you don’t need it anymore.” Compounding also broadens the pharmacy’s customer base by capturing a specific market share within independent pharmacy. “Compounding can be a good niche service and a good source of revenue,” Hauser said. “The more specialized you become, there’s a need to provide compounds to a wider geographical area.” GETTING STARTED WITH COMPOUNDING You’re ready to dip your toe in the compounding water, but where do you start? From sterile to non-sterile, hazardous to non-hazardous, basic to

Common Excuses

Have you made any of these excuses for not compounding? Donnie Calhoun, CEO of the American College of Apothecaries (ACA), eases pharmacists’ fears about compounding. “I don’t have the skills.” All the skills you need to get started you already learned in pharmacy school. Beyond that, there are all kinds of resources for you to grow your skills. Pharmacy associations and compounding suppliers offer hands-on training for whatever stage you’re at. “I can’t afford it.” Compounding can be expensive, but it doesn’t have to be. You can start small, with only a mortar and pestle, and slowly work your way up to more services that require more expensive equipment. “I can’t handle the regulations.” Compounding comes with extra regulations, but the lucrative margins of compounded medications can more than make up for the cost and time required for compliance. You have access to resources and guides to help you stay up-to-date on regulations and to make sure you’re staying compliant.

specialty, there’s an overwhelming spectrum of options. Pharmacies must look at the needs of their community first. “Talk with your local physicians and patients,” Blouch said. “Understanding your audience is the easiest path to success and can eliminate wasted time and money.” Knowing the disease states of patients and the specialties of prescribers will help you find the best approach to generate a return on investment. For

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Types of Compounding

What kind of compounding should you offer? There’s a gamut of options to consider. The best way to determine what you should offer is to meet with prescribers in your community to learn the most pressing and popular needs. Here are a few to know. • Dentistry • Dermatology • Gastroenterology • Hormone replacement therapy (HRT) • Hospice • Infertility • Medication flavoring • Men’s health • Neuropathy • Ophthalmology • Otic (for the ear) • Pediatrics • Pain management • Podiatry • Sports medicine • Veterinary • Women’s health • Wound therapy

example, the veterinary clinics in your community may be outsourcing compounding medications to a pharmacy in another city because no one provides those services locally. After speaking with those clinics, you can gain valuable veterinary business. You’ll likely get patients immediately, which will offset capital costs more quickly and help improve cash flow. “If you’re the only one in a one-hundred-mile radius offering those services, those could be lucrative,” Calhoun said. But there’s no one-size-fits-all approach. “It’s going to vary from one practice setting to another,” Calhoun said. “Look at your patient population and look at the unmet needs occurring in your marketplace.”

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Although it’s crucial to start by understanding local patient and prescriber needs, Hauser said the most successful compounding pharmacies build longterm relationships with prescribers and physicians. For example, create relationships with clinics, zoos, health systems, ophthalmologists, dermatologists and ambulatory service centers—all of which need compounding services. “Pharmacies that have been able to form those partnerships and relationships over time are thriving in the compounding business,” she said. After you pinpoint the best opportunities in your community, Calhoun suggests starting slow. “You don’t go out and start swimming on day one. You put the floaties on first. Then, once you learn how to float on your back and once you can swim under water, before you know it, you’re swimming,” he said. “Pick one thing that you’re passionate about and learn all you can about that. Become the expert in your community in that area.” ABUNDANT RESOURCES Pharmacies that decide to start compounding don’t have to go at it alone. Plenty of resources exist to help them get started and to guide them along the way. From the start, pharmacies should seek the services of a professional compounding supplier that can provide comprehensive training, education and materials. “We consider ourselves a primary supplier, no different than you would have on the finished dosage side,” said Bowman of Letco Medical. “Our professional services team is staffed by compounding pharmacists and techs and we guide the pharmacy through the startup process. We offer a turnkey service to help them get from zero to starting up a compounding offering fairly quickly.” Likewise, Blouch said Medisca helps pharmacies with any compounding need they may have. “Our approach is to address each pharmacy as a partner and to bring value with each and every interaction,” he said. Pharmacy associations also provide helpful resources. For example, the ACA offers two- to threeday ACPE-accredited training courses for pharmacists and technicians in six different areas. Its programs emphasize one-on-one instruction through classes of 12 people or fewer taught by expert practitioners or college faculty members. It also offers webinars, onsite training and home studies. “Training is important at every level,” Calhoun said. “And you want to practice at the highest level because you want patients to have trust and faith that you’re making something for them that’s going to give them a benefit and that’s


going help them get better.” Hauser and Calhoun suggested pharmacists read Dr. Loyd Allen’s International Journal of Pharmaceutical Compounding (IJPC), a bi-monthly, scientific and professional journal emphasizing quality pharmaceutical compounding. Dr. Allen is widely considered the chief guru of the compounding industry. The American Pharmacists Association (APhA) provides an excerpt from Allen’s book, “The Art, Science, and Technology of Pharmaceutical Compounding,” on its website. The book is treated as the standard guide on compounding. “Every single one of our fundamental students gets one of those books to take home,” Calhoun said. Associations, suppliers and academia provide vast resources, but Calhoun stressed that nothing can replace having an experienced personal guide walk alongside you. “You really need a good mentor,” he said. “We all learn from our experiences. So, if you can find someone who’s been there and done that, it makes your path easier. Then, really and truly, the sky is the limit.” THE COST OF COMPOUNDING The cost to start compounding varies depending on the type and amount of compounding services you provide. “On one end of the spectrum if a pharmacy wanted to get into basic compounding, like pediatrics, the startup costs could be as little as a few hundred dollars,” Bowman said. “For larger and more complex compounding like sterile injectables, those are typically found in specialized compounding-only pharmacies. Those startup costs can substantial, in the hundreds of thousands of dollars.” Costs include capital equipment, ingredients, facility formulation, production procedures, specialized training, tools and quality and compliance systems. Compliance requirements force pharmacies to invest in particular equipment, like the reconfiguration of labs and AC systems and protective personnel equipment. “Those costs are pretty large,” Hauser said. “So, you don’t see many people starting from scratch these days or if they do, they go slow and start with non-sterile.” These costs are another reason Calhoun said to start small. “I tell people, you can start compounding with a mortar and a pestle,” he said. “You don’t have to have all the expensive equipment to become a compounder. You can start with basic equipment and start out doing one thing.”

FOLLOWING REGULATIONS Compounding pharmacies are subject to the same regulatory organizations as traditional dispensing pharmacies. They must comply with the Food and Drug Administration (FDA), the Drug Enforcement Agency (DEA) and the state boards of pharmacy. However, compounded drugs aren’t subject to FDA approval, like manufactured drugs. As long as pharmacies fill prescriptions written by doctors, they aren’t considered manufacturers. Additional regulations for compounding pharmacies come only from the state board of pharmacy. The United States Pharmacopeia (USP) details restrictions, requirements and guidelines for compounding, but the state board of pharmacy determines which chapters to enforce and what specific regulations within each chapter to enforce. Because USP enforcement is entirely statebased, the regulations vary widely. “It’s definitely not the same across the country,” Hauser said. “It’s so important that wherever your pharmacy is, in whichever state, you need to be very aware of the rules. It all stems from knowing what your state board requires with compliance with USP.” The regulations also vary depending on the type of compounding. Sterile compounding with hazardous material, for example, faces stricter regulations than non-sterile and non-hazardous compounding. “It’s a fluid world right now in compounding,” Hauser said. “You have to stay on top of the issues and make sure you’re following the playbook as it exists today because it could change soon.” A BRIGHT FUTURE Compounding returns pharmacists to their original roles as preparers of medication offering personalized care. “Compounding gives pharmacists the chance to do pharmacy again,” Calhoun said. “Compounding is the art of pharmacy, it’s how pharmacy started. What drives me is being able to get great patient outcomes by what we do, not by what we put into a bottle.” And the future is up to you. “The future for personalized medication and the compounding business is bright,” Calhoun said. “At the end of the day, it’s all about the patient. That’s why we’re pharmacists to begin with. That’s why we get up and go to work every day. We’re here because we have patients who have needs that can’t be met by the things that are made in factories.”

ELEMENTS | pbahealth.com/elements

19


SPOTLIGHT

Increasing Efficiency How one independent pharmacy owner works smarter by improving workflow

Working at top speed doesn’t have to burn you out. The more efficiently your pharmacy operates, the more prescriptions you can fill and the better service you can provide— with less work. You’ll keep patients happy and increase your profitability. Patients are getting harder to satisfy, so pharmacies have to be quick, said Ryan Summers, Pharm.D., co-owner of Summers Pharmacy, an independent community pharmacy with five locations in western Missouri. “You have to do everything they want—and then some,” he said. “So, you’ve got to get better every day.” Summers Pharmacy uses a streamlined workflow system designed around stations, where technicians, pharmacists and cashiers all have specific tasks to complete. They prioritize, fill and organize prescriptions more effectively, leading to shorter wait times for patients and less stress for employees behind the counter. “We’re more efficient, we make fewer errors, and we have more employee and patient satisfaction,” Summers said. “I’ve had pharmacists come in and do 400 to 500 scripts and say it felt like we did 200. Everyone’s in a

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ELEMENTS | pbahealth.com/elements

better mood and that translates into taking care of the patients better.” WORKING SMARTER, NOT HARDER Summers said his workflow system is more efficient than a traditional pharmacy workflow system because of its organization and paper-free setup. The pharmacy uses its pharmacy management software to complement its workflow system and to eliminate excess paperwork. Traditionally, the pharmacist receives multiple stock bottles, prescriptions, paperwork and the monograph. “As a pharmacist, I don’t want all that junk coming to me,” Summers said. With the workflow system at Summers Pharmacy, the pharmacist only receives the final bottle and the receipt. “There’s not a lot of paperwork crossing over and bottles crossing over, so everybody’s able to be more efficient by taking care of their tasks in their designated area,” Summers said. “Being able to focus more eliminates mistakes and errors.” And, the pharmacist can check the prescription in a few seconds. “I can check three scripts to the one


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SPOTLIGHT

script in the old system that a lot of other pharmacies are using, so as a pharmacist I’m much more efficient,” he said. The workflow system at Summers Pharmacy frees up time spent on the little tasks that accumulate throughout the day, which is important for a busy pharmacy with a high volume. For example, with the right workflow system, you’ll always know where the prescription is. “Instead of the cashier running around

all over the pharmacy trying to find out where the prescription is in the process, the computer will tell them right where it’s at,” Summers said. An effective workflow system also means you can replicate it at additional locations. “All our pharmacies operate the exact same workflow,” he said. “So, any employee from any location can step in and know exactly what to do.”

How It Works

The workflow system implemented at Summers Pharmacy, an independent community pharmacy with five locations in western Missouri, is based on four stations.

Station 1: Input Technicians input the prescription and assign it a priority (new patient, in-store, will pickup, delivery, nursing home, mail, on order, or troubleshooting). For new prescriptions, the hard copy is printed and then filed away accordingly. (The input technicians don’t print any labels.) Station 2: Fill Next, the fill technician prints the prescription label and fills the prescription according to its priority, with new patient and in-store as the first priorities. The filled prescription and the receipt are placed into a basket, which is color coordinated by priority. The fill technicians utilize the ScriptPro® for about 50 to 60 percent of the prescription volume. All other prescriptions go through the Eyecon®. The Eyecon is also used to double count any controlled medication coming off the ScriptPro. Station 3: Pharmacist check Once filled, the pharmacist receives the basket containing the prescription bottle and the

receipt. The pharmacist scans the bottle and checks the prescription. After checking the prescription, no paperwork is printed. The pharmacist simply checks the prescription and places the basket on top of the counter. Station 4: Bin assignment After the pharmacist checks the prescription, the cashier scans the prescription bottle and assigns it to a bag in the will-call bin area. The bag color is based on the day the prescription was filled and each bag has a unique number. When patients come to pick up their medication, they verify their name and date of birth. The computer system will tell the cashier which bag color and number to pull. If the prescription is not yet completed, the computer system will tell the cashier exactly where to find it in the fill process. Workflow notes are inputted during the process and are then printed and highlighted at the bin assignment station along with the drug monographs.

ELEMENTS | pbahealth.com/elements

23


MONEY

Equipment Leasing See how Live Oak Bank helps independent pharmacies with equipment financing

By the Numbers 51 – Percentage of pharmacies

that use an automated dispensing counter

30 – Percentage of pharmacies

that use an automated dispensing system

5 – Number of years of a typical capital lease

Pharmacy workflow and automation equipment can increase productivity and allow pharmacists to spend more time providing patient care. But many independent community pharmacies don’t have the cash on hand to purchase or upgrade expensive pharmacy equipment. That’s where leasing comes in. “The value of leasing is helping business owners preserve their working capital,” said Scott Preiser, general manager of equipment leasing at Live Oak Bank, a bank based in Wilmington, N.C., that specializes in small business loans. “They can hold on to that cash to use for their overhead and they’re able to achieve a real return on investment during the first month of using that equipment.” WHY LEASE EQUIPMENT? Jimmy Neil, general manager of pharmacy lending at Live Oak Bank, said it’s not about leasing or buying,

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$50,000 – $1 million – The

range of financing needed for pharmacy automation equipment Sources: 2016 NCPA Digest, Live Oak Bank

it’s about having financing options. When leasing, there are low monthly payments, no money down, and the pharmacy owner gains efficiencies to make money more effectively, Preiser said. “It’s increasing the pharmacy’s return on investment on that equipment immediately, rather than using cash.” Pharmacies have multiple options for leasing equipment and can turn to their local bank for a loan. Similarly, Live Oak Bank offers an equipment leasing


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program to help pharmacies acquire the pharmacy equipment they need and to maximize their return on investment. Because Live Oak Bank understands pharmacy equipment financing and the lifecycle of the product, it can offer an advantage to pharmacies. “We’re able to establish a no-money-down capital lease with a dollar buyout at the end of the term,” Neil said. “It’s a different credit option than a purchase money loan, which may require 10 percent down and a different rate.” And, he said an equipment lease is more beneficial for pharmacies than a traditional U.S. Small Business Administration (SBA)-guaranteed loan because a lease takes less time to fund. “As we eliminate the governmentguaranteed piece, we’re able to abbreviate applications and requirements and do a conventional leasing product.” HOW IT WORKS Live Oak Bank finances pharmacy equipment from $50,000 to $1 million, including telepharmacy equipment, counting automation, safe workflow automation and packaging, and adherence automation. The term of the capital lease for the equipment is typically five years. At the end of the term, the pharmacy can purchase the equipment for one dollar. Neil said the bank can extend the term beyond five years for more sophisticated adherence packaging products. It depends on the lifecycle of the product and what the pharmacy is comfortable with. “It’s quite an investment and we’re trying to accommodate cash flow needs,” he said.

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ELEMENTS | pbahealth.com/elements

It’s also an abbreviated loan application process. “We typically have a one-day credit turnaround and short form lease documents,” Preiser said. “We’re able to approve quickly and get the equipment faster.” Additionally, the capital lease structure allows for depreciation of the equipment. “You’re able to take full advantage of depreciation schedules according to the current law,” Neil said. “You can accelerate the depreciation of that asset, which could provide some income tax advantages.” A UNIQUE SOLUTION Neil said what makes Live Oak Bank’s equipment leasing program unique is the bank’s presence in the marketplace. “We understand pharmacy,” he said. “My team and I all come from the business. We’re not former bankers— we’re industry experts.” The bank is also technology-focused and has developed an efficient online application and lease processing platform. The bank can process the application and get the lease agreement within a few days. So, pharmacies can forego the frustration that’s often experienced when dealing with a large bank that can’t answer their questions fast enough. And, Preiser said Live Oak Bank treats every customer like its only customer. “We’re developing a relationship and we’re giving them guidance on the best way to finance their equipment and maximize their return on investment on that asset,” he said. “So, we have a consultative role as well as a lending role, which is unique in the banking industry.”


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OUTLOOK

Simplifying Wellness How one company is changing the supplement landscape for pharmacies By Torrie Wright

When patients visit your pharmacy looking to purchase supplements, are they overwhelmed by the options? This is a common scenario for patients looking to start a supplement regimen or wanting to improve their wellness. But it doesn’t have to be. The RefreshinQ Co. offers personalized supplement dose packs, supplement support patches and a customized nutrition program based on an individual’s biomarkers to make supplement shopping easy for patients. The company uses science to create a supplement regimen based on specific goals, like energy, weight support or overall health, which takes the guesswork out of choosing supplements. “The RefreshinQ Co. was developed to make wellness simple,” said George Glatcz, COO of Ritzman Pharmacy, a regional pharmacy chain in Northeastern Ohio and sister company to The RefreshinQ Co. “There’s a lot of confusion and a lot of hard decisions to make when

you’re trying to select the best thing for your body.” Beyond simplifying supplement use for patients, Glatcz said the company aims to create a movement and a community of like-minded people who have a passion for wellness. A UNIQUE OFFERING The RefreshinQ Co.’s supplement packs include a pre-selected combination of vitamins and nutrients packaged into single dose packs. “Essentially what we’ve done is leveraged the technology we use in the prescription business, so we can package multiple vitamins in one personalized dose pack,” Glatcz said. The RefreshinQ Co. pharmacists identified the most common conditions, ailments or situations for which patients are looking to buy supplements and they curated packs based on those needs. “We have curated a blend of vitamins that are already pre-selected and clinically-vetted

ELEMENTS | pbahealth.com/elements

29


OUTLOOK

based on data to have the best use for you,” he said. “Instead of you trying to guess it, we’ve pre-packaged it and allow you to just buy that support pack.” For example, he said many people who are into wellness stop exercising because they get sore and don’t continue their fitness regimen. The RefreshinQ Co. has curated a pack of vitamins and minerals that enable exercisers to push through and continue their fitness journey. The pre-packaged packs include the Workout + Recoverinq Pack, to help enhance a workout; the Daily Multi Replenishinq Pack, to help improve overall wellness; the Blood Sugar Supportinq Pack, to support and manage blood sugar; and the Stress Supportinq Pack, to aid in stress relief. Patients can even customize their own dose pack based on their body’s needs with the Customizinq Pack. They simply consult their community pharmacist to determine what supplements they should be taking, create their own pack on The RefreshinQ Co.’s website and have it delivered to their home. The RefreshinQ Co. also offers a subscription service where patients can automatically have their dose packs sent to their homes each month. “As health care professionals, we know that the more compliant you are, the better your outcome, so we wanted to simplify that process even further by offering an automatic renewal system if the customer chooses to do that,” said Christina Cyrus, general manager of marketing and brand strategy at Ritzman Pharmacy.

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SOMETHING FOR EVERYONE The RefreshinQ Co. doesn’t just offer oral supplements. Patients who can’t tolerate taking supplements orally can get the nutrients they need by wearing a patch on their skin. The patch contains ingredients that the body absorbs over time. For example, Glatcz said athletes like to use the Energy Support Patch, which is designed to help support energy levels throughout the day. They don’t have to worry about getting an upset stomach or experiencing other side effects caused by oral vitamins. The company also offers a Weight Support Patch to help curb cravings and a Vitamin D Support Patch, which provides Vitamin D without the sun exposure. For people looking for a comprehensive wellness solution, The RefreshinQ Co. offers the RefreshinQ Quotient program, which is “where we put our money where our mouth is,” Glatcz said. A simple blood test allows The RefreshinQ Co.’s clinical pharmacists to customize a nutrition and exercise plan that focuses on optimizing four categories of a patient’s biomarkers: strength, energy, endurance and metabolism. “Ultimately, to take the guess work out of it, you have to understand what your body is and is not optimized for,” Glatcz said. “It’s about dialing in on what your body needs. A lot of people supplement just to supplement, but sometimes you need them and sometimes you don’t.” Besides a personalized plan, patients also receive


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OUTLOOK

the benefits of a pharmacist coaching them through their wellness journey. “Most companies are selling supplements to sell them,” Glatcz said. “We’re saying, ‘If you’re skeptical about our supplements and the need for them, why don’t you have your body tell you what you really need?’ and we’ll align the program for that.” EXPANDING PHARMACISTS’ SCOPE Glatcz said Ritzman Pharmacy’s inspiration for creating The RefreshinQ Co. was about getting away from the commoditization of community pharmacy. “A community pharmacy has been commoditized because we focus so much on the production of a prescription,” he said. “This program gives us an opportunity to have conversations with our communities. Not just people who are sick and have prescriptions, but also those who are trying to avoid taking prescription medicine.” The RefreshinQ Co. enables pharmacists to use the breadth of their licenses, gives them an opportunity to interact with more people in the community and generates better health outcomes. “They can expand their use and do things other than medication therapy management (MTM) and traditional prescription production,” Glatcz said. “They can be more on the front line of preventative care.” While Ritzman Pharmacy still believes in the importance of the prescription side of community pharmacy, The RefreshinQ Co. enables the pharmacy to expand its offerings. “Everyone’s doing point-of-care testing and those things, but no one’s really doing preventative care or creating wellness programs,” he said. DIVERSIFY YOUR PHARMACY Independent community pharmacies can benefit from offering The RefreshinQ Co.’s products because they provide an opportunity to differentiate their pharmacy from competitors, Glatcz said. The products can also give pharmacies access to a more diverse population within their community. For example, the Medicare and Medicaid populations are likely a popular demographic at your independent pharmacy. But by enhancing your supplement offerings and focusing on wellness, you may be able to attract a younger generation. “The millennial population doesn’t really want to take prescriptions; they want to be well and better their health every day,” he said. The RefreshinQ Co. offers two programs for pharmacies: a wholesale program, which carries

Supplement Statistics

Do your pharmacy’s supplement offerings meet your patients’ needs? Statistics show supplement use among Americans is on the rise and improving wellness is a common motivator. Take a look at the numbers.

68 percent of Americans take dietary supplements

78 percent of Americans agree

dietary supplements are a smart choice for a healthy lifestyle

51 percent of supplement users take them for overall health and wellness benefits

29 percent of supplement users take them for more energy

67 percent of supplement users exercise regularly

Source: 2015 CRN Consumer Survey on Dietary Supplements

inventory, or an affiliate program, which doesn’t. The company provides a comprehensive training program to ensure wholesalers and affiliates have all the data and clinical background necessary to educate patients and sell the products. Countertop and free-standing pointof-sale displays are available for pharmacies to use in their stores, as well as planograms for those that wish to set up their own display of the products. You can potentially get a leg up on the competition, Glatcz said. As the supplement market continues to grow, patients will be looking for guidance on how to improve their health and wellness. “It gives the pharmacy a chance to do something that Walgreens and CVS can’t accomplish,” he said. Learn more at refreshinq.com.

ELEMENTS | pbahealth.com/elements

33


NOTES

Spread the Word How to successfully market your pharmacy’s flu shots this season Flu season is here, but is your independent community pharmacy ready? If you want to have a successful flu season at your pharmacy, promoting flu shots is key. “Immunizations—specifically flu shots—are one of those diversified revenue opportunities for independent pharmacies to try to set their stores apart,” said John Beckner, senior director of strategic initiatives at the National Community Pharmacists Association (NCPA). “With more and more players in the immunization arena, it’s really important to promote that service.” He said the biggest mistake independent pharmacies can make is to not market their flu shots enough—or at all. SEND THE RIGHT MESSAGE Let patients know through marketing that they can walk in and receive a flu shot any time at their convenience. And, talk with patients to dispel flu shot myths. “Do away with any misconceptions,” Beckner said. “For example, some people may still think you can get sick from getting a flu shot.” But flu shots shouldn’t only be marketed to patients. “Marketing to the medical community is important,” he said. “A lot of physicians have delegated or relegated immunizations to pharmacists, so make sure physicians are aware that you have the flu vaccine and that you are providing that service.” Additionally, he said marketing to employer groups and doing onsite flu clinics can raise visibility. Start marketing early, preferably in mid-summer. “Pharmacies are getting their supply of flu vaccines earlier, so as soon as they have the vaccine they should begin promoting that service,” he said. And, pharmacies need to market the service throughout the entire flu season, which lasts through the end of the year and into January and February. “The

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Promoting Your Flu Shots Market your flu shot services to patients with these ideas.

• Promote flu shots in your monthly newsletter • Send automated text messages • Include information at the point-of-sale • Use an IVR service to make outbound calls • Hang signs in your retail area • Send email reminders • Invest in radio or TV advertising • Contact local physician and employer groups • Go on the air and give a news anchor a flu shot

message then should be that it’s not too late to get a flu shot,” he said. SET YOUR PHARMACY APART Capitalize on the personal relationships you have with your patients. “When you’re providing immunizations and services like that there’s a real trust factor involved and independent pharmacists certainly have that,” Beckner said. Additionally, he said flu shots provide the opportunity for pharmacies to offer vaccine co-administration. “A patient coming in for a flu shot may be a candidate for another immunization, like a pneumonia vaccine or a shingles vaccine,” he said. “Each time someone comes in, it’s an opportunity to take a look at the patient’s immunization record and make sure they’re up-to-date on all their immunizations.”


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HOW MA NY CALO RIES CA 30 MINU N YOU BU TES? RN

Light hou sework Golf (walking ) Walking your dog Gardenin g Shoveling snow Hiking (mo derate) Bycicling (moderate) Tennis Swimmin g Jogging

IN 85 130 150 165 200 210

220 280 300 340

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Elements Magazine - Vol.6 Iss.3 Sept 2017  

Elements Magazine - Vol.6 Iss.3 Sept 2017  

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