What Makes a Great Community Pharmacy

Recently, within the past 2 months, our community pharmacy created a relationship with the discharge navigator of a local hospital.  Our effort was directed at resolving a specific issue that had developed with patients being discharged after a specific orthopedic surgery.  Each one of these patients is discharged on six medications that are part of a specific protocol for this particular surgery.  The issue is, two of these medications quite frequently require a prior authorization with the patient’s prescription insurance company.

Regularly, these patients receive their surgery on Wednesday and then are scheduled for discharge by Friday afternoon.  Upon discharge, the orders would be sent to their pharmacy and the patients would be sent home.  Later that day, their family would go to the pharmacy to pick up their meds and one or two of them would not be ready because they are not covered by the insurance.  Unfortunately, both of these medications are only available as a brand name product, one costs $300+ and the other costs $500+ for a 30 day supply.

Physicians were frustrated because the hospital was discharging patients without their medications that are necessary for their particular protocol and the patients were frustrated because they could not get their medication.  After a few weeks of this scenario, the discharge navigator contacted us in the out-patient pharmacy.  After a few discussions, we set up a plan for the orders to be sent to our pharmacy, with the patients approval, at least 24 hours prior to discharge. 

In an ideal world, 24 hours should be enough time to obtain a prior authorization for these two medications through normal channels.  As we know, quite often, hospital discharges and medical staff availability do not always function in ideal world scenarios.  For the most part, this system has worked well.  We receive the orders in the out-patient community pharmacy, receive a face sheet with the patient demographic information, and begin the process of medication authorization with the prescription insurance company with the help of the physician’s office staff.

Three weeks ago we processed one of these particular discharge order sets.  As fate would have it, the ideal world scenario did not deploy as expected.  The patient’s wife came to our pharmacy Friday afternoon and all of the medications were ready; however, one of them had not yet been authorized by the insurance company.  The cost of this particular medication was a little over $525 for the 30 day supply.

Although the spouse was not too pleased, after a discussion of insurance companies, authorizations and medication protocols, she understood and went ahead and paid for the medication.  We agreed that if the authorization was approved, we would be happy to reprocess the claim and refund her the difference.  Over the next two weeks I talked with this particular spouse on the phone many times.  She had contacted the physician’s office multiple times and had followed up with both the hospital and her insurance company.  Her due diligence concluded with a letter of authorization from the insurance company stating that this medication was now covered.

She was very pleased as she came into the store with her insurance authorization letter; however, I attempted to process the prescription and it still was not covered.  I had a suspicion that the authorization had not been done retrospective, back to the day the prescription had been filled.  I wear a telephone headset at work so it is no big deal for me to get on hold with an insurance company while I continue to process prescriptions and such.  I offered to call the insurance company and see what I could figure out.

After 15 minutes on hold, I let the spouse know that I would be glad to continue the process and would give her a call when we figured it out.  I finally got through to someone, explained the situation and that we needed to change the date on the authorization so we could submit the claim and get a refund for THEIR CLIENT, and the young lady on the other line kindly explained to me that it was not her department, she could not authorize the change and she would gladly get someone on the phone for me who could help me.  This process went on for 70 minutes and 4 different transfers before the issue was resolved.

The catch is, by resolving this issue with excellent customer service and patient satisfaction; we decrease our reimbursement by 15% in order to accept assignment.  On the other side of the coin, the spouse brought us a wonderful box of chocolates and was more grateful for our efforts than words can describe!

So I ask again, “What makes a great community pharmacy”?

Is it the availability of the pharmacists, their willingness to work with you, the different services they offer, that they know your name every time you walk in the door, or one of many other factors we use when we are choosing which community pharmacy we frequent.

As a community pharmacist myself, I would like to think it is a combination of all of these items; however, I believe Customer Service is the number one factor. 

Thanks
Steve

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