How I Think Medicaid Should Work

After dealing with Medicaid for years and seeing how misused and abused the system is. Here is my idea of how I would appropriate it. The goal of my plan is to reduce spending and abuse, while improving total care. Some of this does include using state run welfare as an incentive, but we'll get to that later on. At times this may sound like an oversimplification but I feel the loopholes need to be closed and simplifying Medicaid is a good thing. Here is the total cost of Medicaid by states

Here it is:

1. Start with the same qualifying guidelines based upon the current United States poverty thresholds. These would need to be adjusted on a per state basis as $10,000 in California doesn't spend the same way $10,000 does in Indiana. Link to chart 1. Link to calculator. Link to chart 2. Other guidelines in regards to disability, pregnancy and the elderly would remain unchanged.

2. Cut the age of children covered to only those under the age of 18. I am not sure if all, but I know that at least some states have set coverage to children up to age 19. This may only be a small savings but since childhood ends at 18 for everything else, why not Medicaid? Also at 18 someone can legally go get a job and can support themselves.

3. Limit the number of kids a family is allowed to have on Medicaid to 1. If a family has more than 1 child and is forced to go on Medicaid, the parents will not be covered and a max of 3 children will be covered. This may seem cold blooded at first but why should others be punished for the poor decisions of those who cannot support what they have created. If I were in this situation, I'd be sure to do what I could to keep ALL of my children covered first. This same theory could also be applied to food stamps and welfare benefits.

My own opinion is that Medicaid and related benefits should not be a benefit to having more kids. Unfortunately in my own experiences in retail pharmacy, many people are shown and told from a young age how to ensure the survival of themselves and their family by milking the government system for free entitlements. By the same token I do believe that every person should be given a fair chance against whatever circumstances they come into this world under. To steal a quote from Dietrich Bonhoeffer, "The test of morality of a society is what it does for it's children."

4. Limit the amount of time an adult can be on Medicaid. My personal suggestion would be 5 years consecutively and a maximum of 15 years between ages 18 and 65. This would help to eliminate people who are living on the system while providing coverage enough for them to get back on their feet through tough times. Thus it's a system set up to help people in case of catastrophe and great need, while cutting those who abuse.

5. Random and frequent drug tests as well as checks for misuse and abuse. Although the test itself would be an increase in expenditures, it would help to ensure that those who are on Medicaid are not dealing in illegal activities (whether it be illegal use or selling) and using the government as a free ride. This would also include tobacco as a substance of abuse. I think most people agree that if someone is found to have an illegal substance in their body (marijuana, heroin, not prescribed opiates, etc.) that they are misusing tax dollars and hence forth do not need the assistance they are receiving.

I have seen many patients who use their government provided healthcare to sell what prescriptions they are given to others. This doesn't only include drugs of abuse such as opiates and benzos, but also chronic disease medications (hypertension & dyslipidemia medications). If someone else can't afford a physician's visit or chooses not to have insurance but can treat their disease by buying medication secondhand from someone who gets them for free why not do that? The goal of this clause it to minimize drug abuse Here are a few decent reads: Abuse, Diversion, Fraud, The Costs of Tobacco.

6. Promote the use of contraception. This includes providing easy access to birth control, condoms, Plan B and any other methods a provider sees fit. This would also include allowing patients on Medicaid to bill condoms, contraceptive foams, etc. to their health care coverage without a prescription. The thought being that the increase in accessibility will help prevent the poor from having unwanted children and helps in aiding to reasoning for my #3 point in this article. Interesting article for those with PubMed. Another read everyone can access.

7. Patients with at least 2 chronic disease states must enroll in medication therapy management (MTM) programs and all patients make >75% of all regularly scheduled medical related visits. This is the MOST vital component in this article! This clause would ensure that patients are in contact with healthcare professionals in a manner that has been proven to decrease overall healthcare expenditures while improving the quality of their healthcare. For those of you who think this is unfair healthcare aimed at benefiting the poor you are right. It also benefits everyone else by spending less money and is thus good for everyone involved. Here are two viewpoints on a version of this: The Hot Spotters by the New Yorker and the actual study.

If you can improve care for those who are poor and those who are unhealthy while reducing costs, why wouldn't you do it? Therefore if a Medicaid patient who qualified did not participate their benefits would be cut. If over the course of 2 years they did not show efforts to help control their disease state while enrolled in this program, they would also be cut. Too cold blooded for you? Well, it's a way to help force patients to use these services with hopes that they will listen and improve their own health while saving money long term for everyone else. If they don't take advantage of what they are given, I, personally, do not feel sorry for them.

This is also a major area where pharmacists can intervene and really help further healthcare in the United States. I feel strongly about this as I see and deal with people on a daily basis and can get a good understanding about them with my own interactions with them. This can vary from MTMs to simple medication reconciliation at hospitals and exit counseling. Here are some examples: NACDS, Cost of medication adherence, A Critical Review of MTMs, Do's and Don't's, Cost Avoidance.

8. Charge copayments for every service. This may spark a little controversy but if you include what their expected copays are in a monthly check it will cover them. Why include it in a check then? Why not just waive the copays? This logic is simple; people only respect what they pay for. If they do not feel an out of pocket burden because something is free they will take it for granted. If they know a prescription costs $15 and an office visit costs $25, they will respect it more and will thus be more apt to listen and adhere to what is prescribed.

One of my pet peeves is when people who are on Medicaid complain that their medication is free. Nothing is free. NOTHING! Someone somewhere is paying for it, hence it should be valued at least partially.


9. A stricter formulary.  Every pharmacist and prescriber hates dealing with prior authorizations of insurance companies.  However, in government run systems, as well as privately, they are a great cost savings measure.  Medicaid does have this in place however, a more stringent guideline system could further cost savings.  For example, if every patient was who needed a statin for dyslipidemia where to first try pravastatin for 6 months over atorvastatin, there could be a great savings.  This savings could be even higher if patients were found to be successful on pravastatin, thus eliminating the need to have ever prescribed atorvastatin.  The same rings true for many drug classes and disease states.  This could also apply to even specific OTC versus prescription products such as fish oil (compared to Lovaza) and niacin (compared to Niaspan) as long as they had proper regulations.  This is relatively in place already but an even further belt tightening could save millions.  Just please make a relevant list available to providers with an easy to use interface.

That's about all I can think to modify most current Medicaid systems. Personally, I think any time government expenditures can be reduced and care can be improved it should be done. Since I have now put my views out there, what do you think? I am sure there is plenty to debate here and I look forward to any and all comments.

-The Pharmer

Drugs More Useless Than the Kardashians

These ideas came into my head and my followers on Twitter the other day:

#DrugsMoreUselessThanTheKardasians

(I realize I spelled it wrong but considering the amount of brain cells I lost thinking about these drugs is more than that family has combined it's allowed. So that's where to find them)

1. Reprexain - Because we really need brand versions of hydrocodone/ibuprofen with different amount of hydrocodone!

2. Soma 250mg - No drug abuser wants LESS drug to abuse!

3. Zetia - Poof that only treating will sell for millions of dollars.

4. Aricept 23 - An ounce of benefit for 10 pounds worth of side effects.

5. Treximet - We put a generic headache medicine into your generic headache medicine! Now pay us!

6. Naproxen sodium - Why yes I do have a 20-50mg sodium deficiency that needs supplemented twice a day with my inflammation and pain medicine

7. Vimovo - What everyone needs is another drug that has esomeprazole, isn't covered by their insurance and has an over the counter pain medicine in it.

8. Avandia - Kills diabetes, kills your heart.

9. Tribenzor - When in doubt add two cheap generics to a brand name medications that doesn't get much use.

10. Xenical - High dose over the counter meds that help you leave greasy stains in your underwear must have a prescription!

11. Dexilant - The perfect name for a PPI in case the Teenage Mutant Ninja Turtles need one

12. Auralgan - Add one obscure ingrediant and of course the price should increase ten times!

13. Edluar - Just in case one Ambien CR didn't work, let's make the same drug with a new name

14. Qnexa - In case one stimulant weight loss med wasn't enough, let's add another drug that has some more crazy side effects

15. Intuniv - Make a decades old med extended release and chase a new indication. That should be worth a couple million.

16. Veramyst - Let's take a successful drug and refine the way it sprays while changing the salt form

17. BiDil - Put 2 generic medications in the same pill and market them to minorities! (NO KIDDING!)

18. Naproxen 275mg - Wait, you mean 200 is OTC? Don't tell the insurance companies!

19. Moxatag - Just in case one of the rich suburbanites wants a fancy version of a dirt cheap antibiotic

20. Tamiflu - It's as effective as chicken noodle soup but it comes in a nice little capsule

Any other suggestions?

Should Counseling Be Billable?

Lawyers charge for talking with them in any sort of legal matter.

Physicians usually refer patients to come in before giving medical advice or any sort if they have not seen the patient recently or haven't addressed the issue in question before.

Most public speakers have an honorarium that they are given for showing up in support of a cause or set fee for their speech.

Nurse advice lines usually have a fee of some sort associated with them. If a problem is beyond their level of expertise they refer you to see a physician or nurse practitioner.

Think about it for a minute. Pharmacists provide essential information on how to take and best use a medication, as well as what to watch for and how to best control the problem being treated. Yet they have no real way of billing for this. Whether it takes one minute or an hour shouldn't there be a way to bill for this? This is a professional service, right? It does take my time away from others who need/desire it, that deserves some compensation right?

Now before anyone says I am being greedy, let me explain my reasoning for this. With ever declining reimbursements from insurance companies and PBM's (I'm looking at you Express Scripts!), a pharmacist has to dispense more and more medications to make a pharmacy financially stable. When the point is reached when a pharmacy can not be financially stable nobody wins, except those that created the scenario such as the PBM's. The reason nobody wins is because no patient safety and the quality of care is compromised to dispense a greater volume in less time. If the quality of care declines, so does the overall health of the nation and what is left is a vicious cycle that defeats the original intent. If patient safety declines then you could end up with more side effects, serious drug interactions and possible harm to patients.

Do you see the issue now?

I think it is despicable that reimbursements have gotten so bad (that's a post for another day) but the fact that pharmacists don't get paid for counseling is down right insulting! I know there are MTM services that we can get compensated for but all patients are not eligible for those. Every patient is eligible for consulting the pharmacist about there medication! I think it's actually mandated they must be at LEAST offered consultation in every state.

So if we must give our professional advice and opinions, why aren't we paid for it? The old argument that this "is our

duty" does not hold any water with me anymore seeing how much reimbursements for dispensing have fallen. How can I do "my duty" if it costs me time that forces me to lose money? I can't give professional advice for $0.40 as some insurance companies have proposed!

The solution could be very simple. Have a simple sheet to sign (or credit card like device) that the patient must sign saying the received consultation from the pharmacist. Include in it a simple time spent slot where the pharmacist and/or patient can fill in before they sign. You have complete documentation of how long the pharmacist spent and can be billed appopriately. I doon't think this will produce the positive results seen in full blown MTM programs however, I do think it would produce some significant difference from those who did not receive counseling. This would only apply to patients who were not eligible for MTM programs (i.e. a patient getting a new antibiotic, a methylprednisolone dose pack, etc.). In many cases, the proper use of these medications is vital to reduce rehospitalizations or follow ups, which in turn saves money while improving care.

This isn't a cure all solution BUT I do feel it is a step in the right direction to improve our healthcare.

-The Pharmer

Pharmacy "Discount Cards" = Point Shaving

Point shaving - A type of match fixing where the performers try to prevent a team from covering a published point spread. Unlike other forms of match fixing, sports betting invariably motivates point shaving. A point shaving scheme generally involves a sports gambler and one or more players of the sports team favored to win the game. In exchange for a bribe, the player or players agree to ensure that their team will not "cover the spread". The Gamler then wagers against the team.

- Wikipedia (to keep it sinmple)

Point shaving is illegal and it looked at as a form of corruption. It is usually collusion between sports players and bookies to make a great deal of money at the expense of others who are gambling on the game.

This is exactly how pharmacy "discount cards" work!

Think about it for a minute. A person can usually sign up for a pharmacy "discount card" for free or a very small fee. The user then brings the "discount card" to the pharmacy where it is input into the computer as insurance (on the billing end they are treated the same). The "discount card" will usually reduce the price of your medication based on what the pharmacy markup is. Since brand name prescriptions have a lower markup than generics they have a smaller discount. In most cases I have seen it reduces the out of pocket expense of the prescription to the pharmacy cost plus a few dollars as our dispensing fee.

So how is a pharmacy "discount card" like point shaving?

Simple...

The people who make the pharmacy "discount card" charges the pharmacy (in a few cases the patient) a fee for using their discount services. In many cases this fee ranges from $2 - $5, depending largely on which card is used. On average this fee is ~$3 per prescription. This may sound like a nominal fee for such a discount however; many times these cards make more on the medication the pharmacy dispenses than the pharmacy itself!

These "discount card" makers also give distributors (aka the guy who mails the pharmacy the card or is passing them out) a cut of what they make. His profit is usually somewhere around $1 per prescription. Check out this website and tell me this isn't some sort of crazy pyramid scheme! Here is a pic from the website...

That's right, the guy who made this "discount card" makes more money than I do, despite the fact that I have the product that will improve a patient's health, have a doctorate in the field of pharmacy, assume every single aspect of risk and liability in filling your prescription and even offer consultation on how to properly and best use the medication!

Over the long haul these "discount cards” cut into the overall profitability of the pharmacy. This forces pharmacies to have less tech and pharmacist hours which increases the chance of having errors occur due to increased demands on the workers. Also, by cutting into the pharmacies overhead on the prescriptions, it forces the pharmacy to raise its prices on medications to try to recoup the loss of income associated with filling these prescriptions. Eventually this price trickles over to everyone else as well. Granted most insurance companies are protected due to negotiated prices. The person who really gets hammered is the cash paying patient who has no insurance or "discount card". I promote being your own advocate as much as anyone, but this is really a case of punishing the wrong people: The pharmacy workers and the innocent cash paying patient!

So here is the direct comparison:

Player who shaves points = Patient with discount card

Bookie who makes a lot of money = Pharmacy "discount card" supplier and distributor

People who are scammed by betting = Pharmacy staff and other patients.

The main difference here is that the patient with the "discount card" usually does not know how these cards truly work. Therefore, I must say they are not at fault and I am not blaming them. It's just a shame that the person who gives out these discount cards can make so much money! I must say, I have seen some cards that are handed out by a local county that they either don't take that much of a fee or any at all. I have less of an issue with these cards as they appear to be more altruistic.

All of this points at a big issue in the retail pharmacy industry (and healthcare in general), the need for clearer pricing and compensation guidelines. There will be a post to follow on that at some point, however if we had clearer standards the industry would benefit as a whole. Unfortunately, businesses prefer to do whatever it takes to draw patients in so they can sell them items with higher markups than prescriptions such as soda, OTC diet pills and candy bars. This results in many of them taking these discount cards and over working there associates in a cut throat fashion to make and extra dollar while not truly worrying about patient care.

I encourage everyone to do some research and see who is REALLY getting paid when they pick up their prescription...

Why Can't Pharmacists Prescribe?

I have long wondered to myself, "Why can't pharmacists prescribe?"

The immediate answer is usually "Well they dispense medication and the physician prescribes them. It's always that way, checks and balances!"

It is hard to argue with a system that has been in place for such a long time, but really ask yourself "Why can't the medical professional who is the most focused on medications not prescribe them?" Doesn't that make some sense? If nothing else at LEAST the pharmacists with PharmD degrees have enough education to prescribe, hence why it is a terminal degree in medicine.

To me it just makes sense that an MD or prescriber would write a diagnosis on a prescription and a pharmacist would then select the correct medication for the patient based upon the prescribers diagnosis. Just include all patient labs with the prescription and I can easily come up with a good solution. That is the whole point of earning a PharmD degree (yes the D stands for doctorate!). Many times a day I have to call a prescriber's office to get a medication switched to something else for a variety of reasons. Never mind the amount of times I have to call due to drug interactions or another circumstance in which I give the prescriber my personal opinion on which medication would work for the patient. Doesn't this mean I am basically prescribing for the patient anyways?

Most MD's will admit that even though they know medication they do, to some degree, rely on pharmacists to a good extent. Personally, I catch, on average, 4 significant drug interactions and 8-10 people who are abusing, in some fashion, a controlled substance. On a daily basis I also see upwards of 25-40 patients a day who are not taking their medication correctly or run out of medication while waiting to hear from the physician, nurse practitioner or whoever else prescribes their medications. Many times this is because of cost issues, insurance prior authorizations or wait times to see the prescriber.

With so many patients who are not taking the medications or not taking them correctly, why can't pharmacists use their professional judgement to prescribe a similar medication that is less expensive, is easier to use or cover the period until the patient can see their prescriber? This is a minimal level of prescribing that can save an untold amount of money to the health care system, save the professionals the cost of time dealing with these issues, improve patient adherence and improve overall health care?

Recently there was an article published by the New England Health Institute (NEHI) that reported how non-adherence to medication costs $290 billion to the United States. (Link)

$290,000,000,000!

That's almost equivalent to what the United States spends on medication, which is $307 billion. (Link) That's a lot of wasted money! Money that could be saved by simple adherence to a drug regimen. Even if measures to improve drug adherence cost $100 billion that still saves $190 billion AND improve the overall healthcare provided.

I feel that pharmacists should be able to prescribe if nothing else in a limited role that could help improve healthcare and save money. A pharmacist can note if a patient is not getting their refills on time and counsel the patient as to why. Taking this into consideration the pharmacist could prescribe something that might work better for that patient. Even if a medication costs a little bit more but improves compliance (such as metoprolol ER versus metoprolol) the cost would improve the patient compliance and improve outcomes down the road, thus saving money overall.

This limited prescribing could also lead to changes in some brand name medications to alternative generics or switching a medication entirely if a patient complains of side effects that are limiting the daily activities or causing them other issues that warrant attention. In many cases, does a patient really need to see a prescriber just to get a medicine like naproxen 500mg or to get a prenatal vitamin? These simple medications could be addressed by a pharmacist very easily. All we need is the ability to bill for our services. This charge would be less that MD's and on par with most nurse practitioners, while increasing access to care from an equally qualified practitioner.

The major issue here is communication with the prescriber, which would require some sort of notification sent from the pharmacy to the physician.

Some people may say that medication therapy management (MTM's) is the same thing, yet many physicians who I have either talked to or worked with feel that MTM's are a way to micromanage their practice. MTM's also don't address the urgency that some patients may need or the waiting time to see the prescriber. Personally, I like the idea of MTM's but really feel there needs a prescribing aspect to them to make them excel.

A point that people may point at is the potential for a conflict on interest by the pharmacist to prescribe medications they make a higher profit from. This is a legitimate concern, however, most insurances have prior authorizations in place to stop the use of more expensive medications. If a pharmacist couldn't get these medications covered, they would defeat the purpose of their prescribing role, which is to save money. Also, most generic medications result in higher profits for pharmacies due to the lower cost, hence this is another incentive for pharmacists to prescribe generics. The system already has measures in place that would help pharmacists focus on providing optimal care while keeping the cost of medications low.

Another thing that I find ironic to my point is the hospital system. Many pharmacists will switch medications to similar ones in a hospital because the medication the prescriber wrote for is not on formulary. Wait, isn't that similar to limited prescribing? Why can't all pharmacists do this? Isn't this just further validation of the point that pharmacists should be able to prescribe, especially since it saves money?

Let me also clarify that I am not advocating for pharmacists to replace physicians, especially specialists. They clearly have an important role in providing healthcare. I am advocating for expanding the practice of pharmacy as a way to decrease total healthcare expenditures while improving care. Isn't that one of the major focuses by EVERY political party right now?

I am extremely interested in feedback on this and look forward to hearing from others on it.