What do you want future MDs to know?

[pharmchica15]

Current MS1 at an MD school, but I worked as a outpatient pharm tech for 3.5 years during undergrad for the three letter. (Side note: I applied to go back now and help, but they offered an insultingly low hourly rate (less than what I made when I left for school ) + stipulation that I would have to float to a variety of stores + a variety of shifts. Refused and immediately applied to be an inpatient tech at my local VA; offered immediate start date and higher hourly than I ever had. So now I'm a temp inpatient tech.)

That said, my current med school curriculum is embarrassingly behind on how pharmacy procedures actually work. I volunteered to make a mini presentation on how pharmacy insurance works and how its different than medical insurance. Current topics I have so far include: what PBMs are and how they determine pricing, what a formulary is, prescription copays/deductibles, prior auths etc., and the perils of discount cards.

I decided on these topics based on my personal experience as a tech and what my peers are confused on. Everyone wants to blame the pharmacies for charging so much, but they don't realize how any of it works--many just think we are a**holes that just make up random prices.

That said, I would like as many ideas as possible. Ideally for this presentation they would be centered on mostly pharm insurance, but if the presentation is well received, I would love to do others with different pharm topics.

Thanks!

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[M0df]

I think you have the right idea. I would be even more specific as far as state and local issues. In some places, Medicaid is prevalent. In others, I never see it. So focus on the formulary to avoid prior authorization issues would benefit everyone.

90 day push
State specific regulations on controls

 

[VictorOfHungerGames]

I'm sure you will discover what DIR fees are once you're looking into PMBs but that might be something different than medical insurance. No one really knows how DIR fees are determined and what they entail. Some say DIR fees alone could be killing the pharmacy profession. We get charged tens of thousands without an explanation.

 

[Dred Pirate]

I don't work retail, but I think that is the area there is the biggest disconnect between MD's and Pharmacists/Pharmacies. In addition to what you have already stated.

Retail
1. How do PA's (prior authorizations, not physician assistants) work?
2. Please don't tell patient's the rx will be ready "when you get there"
3. What resources to use to give a guide on pricing? Have any resources to look if drugs are generic? Any lists that show drugs that have just became generic? I admit I am horrible at this - I get asked every so often how much a Rx will costs or what drug is cheaper between two alternatives - I really don't know and usually have to look it up. I don't ever actually work in the pharmacy, so I rarely handle drugs outside of emergency situations, so I don't even know when meds become generic.

Hospital
1. What drugs take a long time to mix up (crofab, etc) and why?

will add more as I think of them.

 

[Pronounce Doxazosin]

Just being price-conscious is all I ask from prescribers
Cost needs to be part of consideration whenever choosing therapy

 

[moose10]

Very important to consider cost when selecting a therapy. Its easy for prescribers to over promise and then for patients to be in a hard spot when they try to obtain their medication.

Other things that come to mind for community and hospital-
Mandatory PDMP use
Medicare paperwork/forms for diabetic testing supplies
Medication safety best practices, especially for institution/hospitals and pediatric patients (ISMP best practices!)

 

[PharmDBro2017]

Be cool about de-escalation of antibiotics.... and do it.

 

[trailerpark]

If you get a new patient that has been on a medication “forever” like Xanax 1mg QID #120 every month that doesn’t mean you should continue it.

 

[Sparda29]

Trust the pharmacists judgment on renal dosing, vanco dosing, coumadin dosing and dose adjustments. It might make life easier for you if you talk to some of the pharmacists in your hospital and come to an agreement about allowing pharmacy to dose certain drugs for you. This way you'll make life easier for yourself and the pharmacy since they won't have to call you and you won't have to return those calls.

 

[owlegrad]

The fact you worked as an outpatient tech mean you probably have a good idea of the intersection of pharmacy, insurance, and prescribers. If I were giving the presentation I would focus on educating on what a prior authorization entails, not making promises on behalf of pharmacy (you don’t know what my wait times or prices are - would you like me to tell the patient when they can get an appointment with you or how much you will charge them?), and finally just try to drive home the idea that we are actually on the same side and want to work together so don’t treat pharmacy like the enemy or foster an us vs them mentality.

 

[zelman]

A lot of good suggestions here. I’d just add that you need to explicitly spell out the “siloing” problem with PBMs when you explain them, and that will tie directly into the concept of prior auths.

 

[RxPreceptor]

Mostly about controlled substances: Would suggest not getting in a prescribing habit of just doing things because "that's how we always do things". When accepting new patients/transitions of care, do not just blindly continue what has been prescribed in the past by other MDs; it's kind of tiring witnessing excessive catering and creating "snowflake" patients who think he/she needs 3 different forms/and or strengths of various amphetamines to get the right therapy (other example - MD using 2 forms of BZDs with different kinetics/substrates...very messy, too many variable to determine how helpful/harmful therapy truly is). Requesting specific maufacturers too...><. Odds are practicing like such will give you and patients more problems with out-of-stocks/disruption of therapy, too much paperwork/PAs, and poly-pharma

Be more direct, adamant in your decisions, and let guidelines and drug monograms (evidence) play a stronger role rather than bending over backwards and playing the catering to the patient card. Always re-evaluate whether a drug is still necessary/when it's appropriate to taper down/discontinue something (more changes/variables @ once = more difficulty in evaluating how successful a strategy was). Do not be afraid to say NO

 

[ranger99rx]

Don't give manufacture coupon to patients with Medicare d, tricare, or government insurance and tell them it will reduce their copay. If you accidentally sent a wrong strength, and send a new strength then put in note to cancel the other one, in stead for us to call to find out which to keep. Read before you send electronic rx, don't send rx for insulin vial and dispense 480 units, 2 set of directions for 1 script, make a habit to include dx code on diabetic supply rx, take as need (how many time per day as needed/max per day), as directected (better option UD on package), send generic drug with note "brand only", change drug/therapy to include note d/c other drugs, especially blood pressure meds, patients often have no clue if they are to continue or d/c other meds. An extra minute to add note save everyone time including yours.

 

[SoylentGreen]

Most important thing - answer us reasonably quickly when we call or fax you. Understand that a prescription is being held up in most cases when you get a call. Resending the same prescriptions with explicit answer to the question is not an answer.

Also don't tell suspected COVID19 pts to quarantine and then give them hard copy prescriptions to take to big box stores like our local ER does.

 

[Wickett]

Probably repeats, but these are usually my big issues I get into as a retail pharmacist.

1. Know how to look up the state's medicaid formulary and be familiar with what's covered or not. Don't tell medicaid pts that everything, including otc products, will always be covered.

2. If writing for controls, esp if multiple controls and/or multiple pain meds, put the dx code(s) on the script. Also, a note explaining why someone is on a combo of controls so we don't have to call and cause delays. If you're going to write for something like tramadol and tylenol #4 and want to claim they're alternating or one is prn for breakthrough pain, make sure the sig and quantities actually make sense for that explanation.

3. Learn how to look up manufacturer coupons and see if someone qualifies for it before writing for an $$$ brand name med, especially for Medicare patients. Be willing to confirm with insurance something specialty is covered and/or pt can pay if not covered before sending it off and the pt over to us. At the very least, inform pt they may not qualify for a coupon/it doesn't guarantee their med cost will be $0.

Have a cheaper alternative possibly available and sent to the pharmacy if the $$$ med isn't covered. I suggest making a reference chart of $$ brand name drugs commonly prescribed and whether Medicare and/or uninsured pts qualify for the mfr coupon or not.

4. Train staff on properly calculating days supply, typing sigs, and sending of scripts in general. Hold staff accountable for escript errors and stress the importance of accuracy.

5. Give specific sigs on all scripts, especially $$$ and/or specialty meds. "As directed" doesn't fly with predatory insurance audits. Body surface area on topicals is expected now. On insulin, if using a sliding scale, at least give the max unit dosage so we can properly give a days supply to satisfy insurance. Overall, just make sure the info on the script is enough for us to properly calculate an accurate days supply and be able to accurately bill to insurance.

6. Know the laws in your state for script writing, especially for controls. Dont use electronic signatures for controls if your state doesn't allow it. Make sure all the info required is on the script, and know what info needs to be provided for mid levels writing controls (ex if supervising physician info and dea# needs to be on there).

7. If there's a potential drug allergy and/or notable drug-drug interaction you're aware of but wish to write the med anyway for a legit medical reason, add a note on the rx with that reasoning.

8. If switching someone to another drug, put a note notifying us the other medication is being discontinued, preferably in the sig itself. This is especially an issue with BP meds, where people can be on multiple ones. Many patients can't keep track of it, and we don't know either. Especially with the rise of auto fills, we need to be notified when something is being discontinued.

9. Know your states Medicare B requirements and follow them so we can get the pts stuff out in a timely manner.

Basically, I don't want to stop what I'm doing to have to call you, and you don't want to have to stop what you're doing to talk to me. The smoother the process, the easier it is for everyone. Despite popular belief, we don't like to "power trip" and hold up and/or refuse fills.

 

[radio frequency]

I would add some info about calculating days supply for items like insulin field and pens (expiration vs pack size vs sliding scales — we need daily maximums!). It would be good if it could be a hands on quiz type thing where you walk them through what we do in the pharmacy to determine days supply.

Explaining that sending a prescription means there is a big filling and checking process still, so the Rx may not be ready in ten minutes; give patients reasonable expectations.

Explaining how days supply effects refill dates. So many MDs think if they write a new Rx, it will go through insurance automatically on that date. Wrong!

I think it would also be beneficial to explain that things like temporary aspirin for anticoagulation after a surgical procedure should have a sig that includes a timeframe. With pack sizes it can be misinterpreted otherwise. If you want it for six weeks, state “for six weeks” in the sig.

Similarly, for liquid oral antibiotics, if you prescribe just the days supply multiplied by the dose, the quantity may be incorrect due to expiration dating and pack sizing. Tell us how long the treatment course should be.

If you are discontinuing a med, add a note to the replacement Rx or call us so we discontinue it on our end, too. If you are aware of a drug drug interaction and wish to proceed anyway, add a specific note to the Rx like “MD aware of DDI/risk of bleed with enoxaparin and warfarin and aspirin; benefits for pt outweigh risk of bleed; please dispense all.”

Lastly, PLEASE let them know that pharmacists are here to act as a resource for them! If you doubt you are entering a prescription correctly, call us so we can help advise! We’re happy to hear from MDs!

All of this will reduce unnecessary calls to your office, if done well.

 

[Splenda88]

Just being price-conscious is all I ask from prescribers
Cost needs to be part of consideration whenever choosing therapy

Most physicians have ZERO idea on drug price. I always tell my patient I don't have any idea, and they will have to do their own research. It would be nice if we had the time to call pharmacy for something like that, but as you all know we have no spare time when we are working. It is not our fault; it's the system.

 

[radio frequency]

Probably repeats, but these are usually my big issues I get into as a retail pharmacist.

1. Know how to look up the state's medicaid formulary and be familiar with what's covered or not. Don't tell medicaid pts that everything, including otc products, will always be covered.

2. If writing for controls, esp if multiple controls and/or multiple pain meds, put the dx code(s) on the script. Also, a note explaining why someone is on a combo of controls so we don't have to call and cause delays. If you're going to write for something like tramadol and tylenol #4 and want to claim they're alternating or one is prn for breakthrough pain, make sure the sig and quantities actually make sense for that explanation.

3. Learn how to look up manufacturer coupons and see if someone qualifies for it before writing for an $$$ brand name med, especially for Medicare patients. Be willing to confirm with insurance something specialty is covered and/or pt can pay if not covered before sending it off and the pt over to us. At the very least, inform pt they may not qualify for a coupon/it doesn't guarantee their med cost will be $0.

Have a cheaper alternative possibly available and sent to the pharmacy if the $$$ med isn't covered. I suggest making a reference chart of $$ brand name drugs commonly prescribed and whether Medicare and/or uninsured pts qualify for the mfr coupon or not.

4. Train staff on properly calculating days supply, typing sigs, and sending of scripts in general. Hold staff accountable for escript errors and stress the importance of accuracy.

5. Give specific sigs on all scripts, especially $$$ and/or specialty meds. "As directed" doesn't fly with predatory insurance audits. Body surface area on topicals is expected now. On insulin, if using a sliding scale, at least give the max unit dosage so we can properly give a days supply to satisfy insurance. Overall, just make sure the info on the script is enough for us to properly calculate an accurate days supply and be able to accurately bill to insurance.

6. Know the laws in your state for script writing, especially for controls. Dont use electronic signatures for controls if your state doesn't allow it. Make sure all the info required is on the script, and know what info needs to be provided for mid levels writing controls (ex if supervising physician info and dea# needs to be on there).

7. If there's a potential drug allergy and/or notable drug-drug interaction you're aware of but wish to write the med anyway for a legit medical reason, add a note on the rx with that reasoning.

8. If switching someone to another drug, put a note notifying us the other medication is being discontinued, preferably in the sig itself. This is especially an issue with BP meds, where people can be on multiple ones. Many patients can't keep track of it, and we don't know either. Especially with the rise of auto fills, we need to be notified when something is being discontinued.

9. Know your states Medicare B requirements and follow them so we can get the pts stuff out in a timely manner.

Basically, I don't want to stop what I'm doing to have to call you, and you don't want to have to stop what you're doing to call me. The smoother the process, the easier it is for everyone. Despite popular belief, we don't like to "power trip" and hold up and/or refuse fills.

I should have read your post before posting. You covered 95% of what I wanted to say!

 

[owlegrad]

Most physicians have ZERO idea on drug price. I always tell my patient I don't have any idea, and they will have to do their own research. It would be nice if we had the time to call pharmacy for something like that, but as you all know we have no spare time when we are working. It is not our fault; it's the system.

if a drug rep comes to talk to you about the drug I guarantee it’s expensive.

 

[radio frequency]

if a drug rep comes to talk to you about the drug I guarantee it’s expensive.

Buuuut it probably also has a manufacturer’s coupon? So, if your patient isn’t on Part D or Medicaid it may be ok?

 

[radio frequency]

Buuuut it probably also has a manufacturer’s coupon? So, if your patient isn’t on Part D or Medicaid it may be ok?

Sorry owle. I know, those coupons drive up everyone’s costs. But sometimes (very occasionally) that medication and coupon are the best thing for that individual patient. Know your medicines though.

If there’s a very reasonable alternative to something super expensive, use it (like, don’t be prescribing AuviQ over Epipens; that is ridiculous and AuviQ costs are insane to health plans but the coupons make them look cheap to patients).

 

[beautifulrobot]

There are a lot of great suggestions already mentioned here. I'll just add these two points:

- Stay focused on the drug pricing part - it's your strength and what you know best. Trying to cover all of the points in this thread may overwhelm your MS1 classmates who are already overloaded with information and whose priority is passing Step 1 / getting pubs / sucking up to attendings. For the most part, they couldn't care less about what pharmacists want them to know. Maybe have an addendum/handout to your presentation that lists many of the other valid things brought up here. In short, play to your strengths and remember who your audience is.

- On a similar note, how many of your classmates are HPSP/have a military obligation? Drug pricing might not be as applicable to them. You may want to include a discussion of what a drug formulary is and why its important - this would be relevant to both the future civilian/private practice physician (private PBM formularies) and uniformed physician (VA and Tricare PBM formularies). There are some really interesting ethical considerations with formualries, and they tie in well with the overall topic of drug pricing. Bringing up these ethical questions may be a good way to engage your audience, as well as provide them a better understanding of why prior auths exist/why the VA/DOD pharmacist keeps telling them they can't prescribe X until they've tried Y and Z.

 

[297point1]

I want physicians to know that KevinMD is an inarticulate ignorant dope.
Don't be like KevinMD.