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Friday, October 30, 2009

In the olden days if a Mafioso ratted on somebody he'd get thrown off a bridge or tossed off a rowboat wearing cement shoes. Nowadays nobody's ratting on nobody. And why's that? Because the new mafia has made it darn near impossible to rat anybody out, just because it's all so stinking complicated that hardly anybody knows what's really going on.

But the end game is still the same: kill any bugger that gets in your way or costs you money.

When somebody gets killed every half hour in this country you'd think it might just get noticed. Nah. First you'd have to know the links, how it all fits together. And with a body on the floor who's going to notice the dozen different things that caused it to happen in the first place? Nobody, that's who.

Here, I'll give you an example. Say Johnny Walnuts starts to notice his crew isn't taking in nearly as much as it did last year. So he ups his premiums, say. Things start to look better, but not as much as Joe, aka "Prior Auth" Lucchese, the Godfather to his cronies, expects to get from his pals. So he thinks, Maybe double the copays. Yeah, that's the ticket. Oh, and while we're at it we're going to put limits on cancer drugs. And biological. Heck, anything that costs a lot. People will assume they're still covered, but they won't be really. If they get the Big C, Joe says, then we're collecting the benefits without paying the dividends, see? Beautiful!

Everybody saw the beauty of it: big money flowing in, very little paying out. And with every little bit of small print added the complicated became even more complicated, which just meant fewer and fewer people would be able to connect the dots. The Barzini family at Aetna, the Tattaglias in Humana, the Corleones of BC/BS, and the smaller families that feed off the crumbs left them, they all began to multiply the separate plans within each family, until there was over ten thousand different "insurances" offered over the entire country. Each had the same complicated structures—which the families changed month to month without even notifying anyone! The plan worked perfectly, until some smart accountants started noticing all the money we'd been spending compared to other countries. They thought that maybe the country was getting ripped off. Of course they were right.

When it turns out that some poor schmuck's cancer isn't covered the guy can't afford the treatments. First, he goes bankrupt, then he dies. The girl waiting for the new liver never gets it approved. Sure the girl's mom takes "The Company" to trial but by then it's way too late. And the company's lawyers still get paid! Oh the plan is so perfect the old time Mafia must be weeping over their beers. They thought they had it good, knocking on the doors of a strip joint and speak easy, "asking" for insurance money just in case somebody might happen to want to burn down their joint. The real money, they learned, was in the real, actual insurance business. The new mafia is making mince meat out of the old, all the time acting like they're all hot shot businessmen. They even have their own political party, the Republicans, to try and complicate things even further, blaming government for the mess. Can you imagine! That'd be like the Gambinos blaming the FBI for all the mafia mess. The weird thing is that it's working. It's like somebody once said, killing is their business, and business is good.

Sunday, October 04, 2009

If the pharmacy industry can finally solve the riddle of how to serve a patient's need for personal consultation (now vastly underserved) while demanding more and more of the pharmacist's time, then we will enter the next stage of medication management.

As I wrote earlier, robot dispensing of medications holds great promise to free up the pharmacist to actually do what he/she is trained for: medication management (known in the biz as MTM, short for Medication Therapy Management ), inoculations, and training patients to better manage their disease states.

It is amazing that students spend six years in training for disease and medication management but when introduced to the business world none of what the newly graduated can offer is actually used.

Can pharmacists reduce the costs of health care by catching provider errors? Yes.

Can pharmacists reduce hospitalizations, and emergency room use through Medication Therapy Management, increasing adherence to medication use? Yes, again.

Could pharmacists save doctors time (and money) by being allowed to make therapeutic substitution when the insurance denies certain claims? Of course.

These are all proven. MTM is even now included within Medicare reimbursement to providers. There is really only one missing piece: Time.

No one has the time to actually talk to patients. No one has the time to give vaccinations. The only thing I have time for is to dispense one prescription a minute. Barely. Even with robot use, as in Rite Aid and Walgreens, time is still a precious commodity. There are too many silly regulations by state boards that waste a pharmacist's time (make sure that you sign every single line of that 222 form! And date that invoice that is already dated. And put that address on the line that the doctor was supposed to put in even though it's already in the computer record.)

The pharmacy of the future holds great promise. I see technicians doing pretty much what pharmacists do now, possibly even including the verification stage of prescription processing. Technicians aren't going away, even in a robot driven world. They will always be needed. And pharmacists too will be needed, just differently, to be used instead as a real member of the health-care team, instead of as an ancillary player. We simply have too much to offer to be ignored for much longer.

I've been wondering lately if retail pharmacy is dead or at least ready for some major triage.

It's not that the local pharmacy is going to go the way of the dinosaur. Pharmacies will never disappear. But I do think they are going to evolve into a different "animal" than what we see on the corner now. I say that because of the different circumstances faced by the retail druggist than existed even just five years ago.

In January of 2006 millions of elderly Americans began prescription coverage with Medicare Part D. This was not only a boon for seniors; it brought increased foot traffic into drug stores. The volume of prescriptions filled sky-rocketed. Then a couple of years later Wal*Mart brought its own brand of insurance reform by instituting their list of $4 medications. In an industry not known for creativity this was an earthquake high on the Richter scale of business practices. It brought price point back to prescription drugs, competition where none had existed for years. "Me-too'ism" crept in and soon Target and Rite Aid and CVS and everybody else soon had some version to compete with Wal*Mart. More foot traffic. More volume. More prescriptions than could be filled quickly and safely.

Back before the days of Medicare Part D we routinely told our customers that we could have their prescriptions filled for them in under fifteen or even ten minutes. Now we doubt very much if we can fill anything in much less than forty-five minutes. We may say "a half hour" but we really mean "we're going to hope for less than an hour unless we get some insurance problems which really is a given anyway."

Can we keep traveling on this road? As baby boomers age the numbers are going to go up astronomically. Things are going to have to change. Something has got to give.

Robots might be introduced. Rite Aid first got on board with robots back in the late '90's, but I see all drug stores eventually filling scripts with robots within the next ten years. Or five. This is one of the things retail stores must learn from mail order firms. You simply need a fast, efficient, and safe way to fill more than one prescription a minute and robots are the only way to do that. Although the public will balk at first they will eventually see that getting their prescriptions fast will be a nice trade-off to an unfamiliar system. And whether they know it or not the millions of people already receiving their medicines from a mail order company get their scripts processed by robots.

So the next time you wait an hour or two you might want to reconsider your aversion to mechanized pharmacy. Science fiction isn't just for trips to Mars. It might be as close as your corner drug store.