What You Need To Know About Asthma Inhalers

Our dedicated intern here at AudibleRx, Luka, has completed and posted for us a fantastic video describing the importance of understanding how to use your inhalers for asthma treatment.

For complete Consumer Medication Information regarding your asthma inhalers, please visit the INHALERS PAGE at AudibleRx and listen to the counseling session about your specific inhaler.


Over the past 18 months we have been fortunate to have an intern working with us here at AudibleRx.  Luka Tehovnik, a recent graduate of pharmacy school from the University in Ljubljana in Slovenia, has helped us with quite a few projects here at AudibleRx, including the development of the opening video, the Alphabetical page and the cool icons on the home page.

Susie and I greatly appreciate all the effort Luka has put into his work with us these past 18 months. We are looking forward to visiting with Luka for two days this October as he passes through the Bay Area on his United States tour, we congratulate him on his recent graduation from pharmacy school and wish him the best in his pharmacy career!

Steve and Susie Leuck

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How does a Pharmacist GET PAID for Consulting Services?

Jonathan Shores oversees the operation of a Non-governmental Organization (NGO) charged with the mission of providing free annual Influenza Immunizations, free Pneumonia Immunizations, and free MTM pharmacy services to a growing target population of 22,000 seniors aged 65 years of age or older.  Emphasis is placed on providing in-the-home immunization services and immunization services at scheduled social clinics at each of several county locations.  Particular emphasis on serving the needs of physically home-bound, socially home-bound, and economically home-bound individuals is observed.  Jon is on the front lines, as a pharmacist, providing pharmacy services; all the while laying down the track on how to be paid for these services.  We owe Jon a debt of gratitude for his work in this field and are fortunate to have him as a guest blogger today on the AudibleRx Blog page.

Pharmacists work at the short end of some pretty restrictive provider agreements: networks with severe enrollment exclusions, mandatory mail-order, parsimonious prescription promises with poison pill payoffs, onerous minimum drug purchase requirements, just to name a few. The raison’d etre for boxing providers out is always the same: a monopoly that promises great gobs of cost savings for the American healthcare system. Whether these savings ever materialize or not, depends on who you ask, and how long you are willing to listen. The promise often carries more weight than the result. The latest adventure in restraint of practice involves Medication Therapy Management, MTM. It’s like deja’ vu all over again.

There is no problem finding pharmacy consultants able to provide counseling for eligible patients. A terrific certification program sponsored by APhA, and a splendid how-to manual called, “How to Conduct a Comprehensive Medication Review: A Guidebook for Pharmacists,” by Lauren B. Angelo and Jennifer Cerulli; have served to populate the playing field. The consulting process has been well defined: locate an eligible patient, gather data, identify and perform needed services, exhaustively document all work, perform the billing, then compile everything into a comprehensive, legal and durable health record.

The problem is how to get paid for the work that is done: bill insurance companies directly for the work, or hire a third party to do the billing. A popular method of getting paid is to buddy up with one of several companies that bill MTM services. The consultant gathers some data and performs some services, enters the work into some web- forms, and collects some fee for service. There are some perilous shortcomings involved with this approach.

Consider the following excerpt from page twenty-four of “How to Conduct a Comprehensive Medication Review: A Guidebook for Pharmacists”:
“Thorough and accurate documentation must be completed for all MTM encounters with patients. Documentation helps to justify payment for the service, and it may be needed if the pharmacy is faced with an insurance audit by the payer or CMS. Any documentation resulting from an MTM encounter with a patient becomes part of the patient’s medical record. Medical records are considered legal documents. If legal circumstances such as lawsuits or suspected insurance fraud arise, medical records, including the documented MTM, can be subpoenaed for use in court.”

The parties empowered to solicit this information from the pharmacy of record include: officers of the court, insurance auditors, law enforcement officials, and Hipaa-enabled patients. Each can reasonably expect to receive a comprehensive, legal and durable health record upon request, and in timely fashion.

Pharmacy consultants who use billing companies usually do the following: collect a limited amount of defined patient data, identify and perform services, enter the data into web-forms provided on a billing company website, and then collect a fee. The data held by the pharmacy consultant is often discarded after the fee is received. The billing company evaluates the data entered into the web-forms, creates a billing plan, bills the insurance, and then pays the pharmacist fee. The two parties seldom collaborate to combine the separate pools of information into one complete whole. The comprehensive, durable and legal health record that should be conserved by the pharmacy provider seldom results.

Billing companies negotiate exclusive provider agreements with many of the largest insurance providers. These small companies with limited resources have pledged to consult tens of millions of patients who are federally entitled to Medication Therapy Management services! Each billing company serves not as a convenient “gateway” to billing an insurer, but rather as an exclusive “gatekeeper.” A pharmacist who consults a patient who is insured by a contracted insurer must utilize the billing company contractor to get paid, even if the billing arrangement fails to meet minimally legal conventions for keeping health records.

These MTM billing arrangements restrain the practice of pharmacy consulting, foster poor record keeping practices, limit access to healthcare services, rob patients of health benefits and cost savings, and prevent the public from benefiting from the “best and the brightest” people our profession has to offer. Add them to a malignant list. Monopolistic arrangements are a common thread in the fabric of pharmacy practice, and dealing with them has become an integral part of the job. Expect to see such agreements occur again and again… and all over again.

“How to Conduct a Comprehensive Medication Review: A Guidebook for Pharmacists,” Lauren B. Angelo and Jennifer Cerulli, 2014 The American Pharmacists Association

Thanks to Jon for the post.

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What Every Pharmacist Needs

You know how it is, you're in a hurry, using your fast walk down the hall way, where ever it is that you work.  You turn the corner and there's the person you've been needing to ask a question of.  Politely you  interrupt them and ask if they have just two minutes to spare for a quick question.  "Of course, what could I help you with?" they say.  In less than four seconds they have taken their focus off of all that they were doing and given you their 100% attention. 

Somehow, they have quickly made you feel as if your question is the most important item they have been requested to address all day.  They listen intently, allowing you to finish your sentences without rushing.  Interestingly, it feels as if they understand exactly how you feel about the concern you are expressing.  Even though it has only been two minutes, you were sure it must have been at least five or even ten minutes.  You leave the interaction with an assurance that you have been heard and are completely satisfied with the interaction and response.

We have all had interactions where we walk away less than satisfied with the response from the other individual.  For that matter, I am sure that many times individuals have walked away from us with similar dissatisfactions.  What is it that distinguishes an individual in a conversation?  What characteristic does someone have that quiets them and helps them listen when the other person is speaking?  Why does one person understand what the speaker is discussing and respond appropriately while the other is reminded of a story from their life and immediately routes the conversation in another direction?

Bartenders got it, barbers got it, therapists and counselors defiantly got it; and now, we expect pharmacists to have it!
Pharmacists , who have been tied behind pharmacy counters for years, complaining that they are underutilized in their clinical skills, are being pulled, kicking and screaming, out in front of the counter to talk with patients.  As a matter of fact, we don't just want you to talk with the patient about their medications, we want you to also educate them about their disease state, address their barriers to effective medication adherence, help them understand the consequences of not participating in their medication regimen, thoroughly explain their prescription insurance options to them, check in on them when they are in the hospital to assure their medications are reconciled appropriately, and then call them on a regular basis after they leave the hospital to assure they are maintaining adequate control of their ever expanding pharmaceutical world.

Don't get me wrong, I am all for it.  This is a truly exciting time in the pharmacy universe and I want to be part of the huge solution.  My concern is that not all pharmacist are ready for this process.  We are good at what we do.  We have been trained in all aspects of the science of medications.  Computer verification, dosing calculations, drug interactions and therapeutic duplications, heck, even the occasional telephone call to the physician's office for an order clarification.

Whether it be a patient picking up a refill with a quick question, an extended medication counseling session at the pharmacy counter, a visit to the patients hospital room prior to discharge to discuss their new medication regimen, or an full Medication Therapy Management session with a patient in the pharmacy or at their home; each visit with a patient is an opportunity to listen to their concerns, better understand their difficulties, and offer reasonable and empathetic suggestions.

As a colleague recently shared with me, "Medication counseling is an acquired skill which takes not only knowledge but communication skills which must be patient specific and flexible based on patient feedback."

When talking with patients, the communication required involves training and tact, needs to be patient specific and dynamic enough to change in the middle of a counseling session based upon a patient's changing situation and feedback.  In essence, a skilled pharmacist will be in a position to identify with and understand their patient's fears and concerns in order to assist them effectively and appropriately with their medication regimen.
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Motivational MTM

No matter how old you become, you always remember what it felt like on game day.  In the locker room, all suited up, nervous tension about the game to come and perhaps a little anxiety about the size of the other team.  You hear a couple of the lineman hitting each other's shoulder pads with ferocious intensity.  The team is getting a little rowdy, the sound of hands banging against the metal lockers.  Then, the Coach walks into the locker room.  Quickly the room is as quiet as church at the 6 a.m. service.

The Coach isn't there to talk about the plays we are going to run that day.  He doesn't want to discuss how we did at last week's game, or for that matter, what the plan is for next week's game.  Right now, right here, the Coach is here to talk about today.  What are we doing here?  Why did we take the time to put on our uniforms?  How are we going to reach deep down inside ourselves and draw upon that strength that will allow us to go out there and give the game 110% of our effort!

We are familiar with traditional Medication Therapy Management, its core elements, and all that goes into a complete session.  When talking with patients we use the techniques associated with one of the latest catch phrases in the health care field called Motivational Interviewing.  I have yet to see anyone combine the two into what I would like to call Motivational MTM.

Pharmacists are being called upon to step up, take responsibility, and help bridge the medication-education-gap that exists between patients, and their health care providers.  Medication Therapy Management is one way in which pharmacists are playing a central role in assisting patients understand and manage their mediations. 

Motivational interviewing, on the other hand, is a patient-centered method for identifying an individual’s readiness for change and enhancing motivation by exploring and resolving ambivalence about the new behavior. These techniques, such as open ended questions, reflective listening, and summary statements help promote informed decision-making and encourage patients to participate in their own health care.

One particular arena where pharmacists are being called upon, in a transition of care, medication education capacity, is to help patients who are being discharged from hospitals maintain an appropriate level of adherence to their medication regimen once they return home. 

I would argue that patients are not in their best state of mind while they are hospitalized.  It would be inappropriate to assume that a patient, educated about their medications while in their hospital bed, would be in a position to recall all of the specifics of their education once they got home.

Perhaps this would be an opportunity to implement a Motivational MTM program.  Sure, the patient is excited and ready to go home.  Here comes the pharmacist with a stack of papers and says, "WAIT", I know you are ready to leave; however, before you exit this hospital, it is my intention to discuss each and every one of your medications with you, while also highlighting on these papers all of the important aspects of your medications so when you get home you may read through them again.

Instead, how about if the pharmacist comes into the room and shares a little empathy with the patient and their family.  Understanding that they have just been through this tremendous process and would like nothing more than to leave and get to the comfort of their own home.  Heading home; however, means that they will now be the ones responsible for managing their medications.  Are they ready for this task?

As the Coach said, What are we doing here? Are we ready to take on this task? Are we ready to reach deep down inside and come up with the strength that will allow us to give 110% to adhering to our medication regimen?  

Sure, Motivational MTM can include some open-ended Vince Lombardi one-liner questions; however, it also needs to include some brass tacks of adherence.  Patients need to fully understand the daunting statistics that surround adherence so they realize what they are up against:

      • 75% of adults are not adherent to their prescription medication in one way or another.
      • 125K deaths in United States each year due to non-adherence.
      • Up to 69% of all medication related hospital admissions are due to non-adherence.
      • Non-Adherence costs the country up to 300 billion dollars/year.

Before a patient leaves the hospital, it is imperative that they understand what their specific barriers to adherence are.  Whether it be cost of or access to medications, social or religious, mental or familial, or one of the many other barriers, a discussion needs to take place so these barriers may be addressed.

The pharmacist may also help a patient understand what it means when they hear the term, Health Literacy.  With a little help, a patient should be in a position to describe their diagnosis in one or two sentences while also describing what treatments have been employed to treat the specific diagnosis.  Furthermore, and possibly more importantly, the patient should be in a position to describe the consequences of not treating their diagnosis.

Lastly, patients need to understand that their community pharmacist is a valuable Medication Information and Health Literacy resource. Patients, at all points along their health care continuum, should be encouraged to develop a relationship with a community pharmacist they trust. 

Now it's time for the patient to head out the door, get in their car and head home.  The have completed a 20 minute Motivational MTM session with their pharmacist;

  1. They understand what drug adherence means and the challenges it poses.
  2. They have a much better understanding of their specific barriers to medication adherence.
  3. They are able to voice their diagnosis and clearly identify the specific treatments for each diagnosis.
  4. They know exactly where they will go for follow up questions and concerns about their medication regimen.

OK team, now let's get out there and give it all we got!


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Student Loan Debt; Is It Worth It?

Students, pharmacy or other, will sometimes be faced with the daunting issue of student loan debt.  Is it worth it?  Personally, the debt I incurred as a student during the early 80's was worth every penny.  My wife and I paid a mortgage sized student loan payment (albeit, 90's style mortgage) for 10 years until the debt was paid. 
Eric Christensen, Pharm.D. is a Board Certified Pharmacotherapy Specialist as well as a Certified Geriatric Pharmacist.  Today we have the honor of having Eric as a guest blogger on AudibleRx.  As Eric says on his www.meded101.com website:
Nobody cares how much you know, until they know how much you care.  – Theodore Roosevelt

The Dark Side of Being a Professional Student

I’ve had my share of challenges to overcome, but overall consider myself pretty successful thus far at the 30 year mark.  Getting into pharmacy school, passing pharmacy school, and simply getting a job I enjoy are a few of the professional successes I’ve worked for.  There is one part of my and now (my family’s) lives that needs some tuning up.  My student loan debt.  I was the idiot in college that thought to myself “debt is a part of life, so why wouldn’t I take out the maximum amount of loans each year so I had plenty of cushion?”  Maybe idiot is too harsh, but I certainly went along with the crowd whom many are now in the same position I am.

I graduated in 2009 from pharmacy school with nearly 150K in debt.  I’ve made substantial progress, but still have a ways to go.  Married with two small children and a house payment, the income can go pretty quickly, leaving not as much as I’d like to tackle that debt.  If you’re going through pharmacy school, you will likely have more or less depending on the number of years, scholarships, help from family, and cost of your program.  I make a nice salary as a healthcare professional, and you likely will or do too.  However, what you may not think about is the future.  The rain cloud of student loan debt hanging over your head doesn’t care about your life.  I’m writing about this issue, because I did not have much guidance when I was in school and am hoping that someone will listen.

If I asked you the question, “Would you rather be in debt or out of debt?”, what would you say? – Pretty easy answer.  I’m asking you to NOT accept the notion that student loan(s) and their repayment are a lifelong experience. 

Let me give you one statistic – Your interest payment in one month at 6.8 % (maybe yours is higher or lower) for 150K is over 570 dollars.  You could do a lot of good and/or have a lot of fun with an extra 570 dollars a month.

While money certainly gives you the opportunity to take a trip of a lifetime or buy something ridiculously cool, there is something intangible that you may not have thought about.  Money gives you freedom – and to many this is the greatest gift of all.  Take on a new project you’re passionate about, donate your time to a cause you care deeply about, spend more time with your family, are all perfect examples of what you may be sacrificing by having to work to pay “the bill”. 

My advice: To future healthcare professionals, do everything in your power to minimize your student loan debt – you will not regret it.  Start today.  Develop a plan and execute it.  If you’ve recently graduated and have a mountain of student loan debt in front of you, my advice is to make an aggressive plan by minimizing lifestyle and frivolous things, then start climbing.  Don’t wait on this, your future you will thank you. 

Appreciate the opportunity to guest post on this important issue!  You can find me educating the healthcare world on medication management principles at www.meded101.com

Eric Christianson, PharmD, CGP, BCPS

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