Five Pharmacy Pain Points – And The Technology Solutions That Can Minimize Their Impact

Introduction

Pharmacists ranked near the top of Gallup’s 2023 list of “most ethical” professions, coming in third after nurses and doctors, with 58 percent of respondents giving pharmacists either a “very high” or “high ranking.”  These sentiments seem to affirm findings of a survey by the Columbia University Mailman School of Public Health, which found almost 80 percent of patients said they consider their pharmacist “an integral part of their healthcare team.”

The high regard patients have for their pharmacists is certainly justified, given the front-line role pharmacists have in not just ensuring patients receive their medications, but in providing an increasing array of health-related services.  And while patient care will always come first, pharmacists must also contend with the multiple day-to-day challenges that affect pharmacy operations.

The term “pain point” is often used to describe these challenges, and it is an apt description.  Merriam-Webster dictionary defines a pain point as “something that is a recurring source of trouble, annoyance, or distress.” Unfortunately, many tasks associated with operating a pharmacy meet this definition.  

While topics including direct and indirect remuneration (DIR) fees, reimbursement rates, time constraints, regulatory requirements, and overall profitability are top of mind for most pharmacists, the list seems to grow with every pharmacist asked to offer an opinion.

“Inventory costs,” one New Jersey pharmacy manager said, noting that she doesn’t always buy medications from her main supplier but instead continually compares prices to get the lowest price possible.  “It’s the difference between losing business and being able to make a profit, and we’re literally talking about finding an extra $5 here.”  This pharmacist also cited the high level of clinical services administered to patients, for which she is not reimbursed.

“Not enough time for patient interactions,” was a frustration voiced by another pharmacy owner, this individual with three pharmacies located in the New York City region.  If it was up to him, this owner said he would spend the bulk of his time interacting with patients and expanding programming and outreach efforts.  But the realities of pharmacy ownership seem to take up more and more time.

The list is certainly long.  But there are solutions.  Resources are available to help pharmacists navigate these challenges, most notably including technology-based solutions that can automate workflows and seamlessly perform tasks that used to require chunks of staff time.  The PrimeRx pharmacy software solution is a good example.  With PrimeRx a pharmacist can have confidence that core functions are seamlessly managed, and problems solved.  This includes dispensing, refills management, inventory, claims processing, signature compliance, and records management, to name just a few of the solution’s capabilities.

As pharmacists assume an even greater role in patient care, while maintaining core dispensing responsibilities, feelings of “not enough hours in the day,” are certain to increase.  But as the following discussion will make clear, pharmacy-based technology solutions can be a critical tool in managing the workload.  Pharmacy software systems, including PrimeRx, have kept pace with changing pharmacy needs and are poised to help.  

Pain Point #1 — DIR Fees: Managing the 2024 Transition and Beyond

DIR fees are a leading cause — perhaps the leading cause — of economic strife among pharmacists.  

According to the Centers for Medicare & Medicaid Services (CMS), DIR fees were included in the original federal Medicare legislation as a way to allow CMS to account for rebates and concessions paid by manufacturers to plan sponsors and pharmacy benefit managers (PBMs).  

However, the fees have become highly contentious as PBMs increasingly impose retroactive assessments on pharmacies – a practice referred to as “clawbacks” -- long after the patient has received the medication in question.  

CMS research cited a shocking 107,400 percent increase in DIR fees over the 2010-2020 period.  For the typical community pharmacy, this has amounted to an estimated $81,000 in fees each year, according to the National Community Pharmacists Association (NCPA).

It's hardly surprising that DIR fee reform has long been a top priority for the many trade associations, including the NCPA, the American Pharmacists Association (APhA), and the National Association of Chain Drug Stores (NACDS).  In a 2019 statement to the Ways and Means Committee of the U.S. House of Representatives, NACDS cited the “unknown, unpredictable, and inconsistent” nature of the fee assessments, and the tremendous strain DIR fees have had on community pharmacies.  

Years of effort were finally rewarded when in 2022, CMS issued a final rule outlining a restructuring of the DIR fee assessment process.  Beginning in 2024, fees will be assessed at point-of-sale, thus bringing an end to the retroactive assessments.

However, pharmacies have been warned to expect short-term cashflow issues during the first half of 2024, as the new process overlaps with a final 2023 “clawback” assessment.  

Essentially, pharmacies can expect an immediate drop in revenue, since rebates and concessions will be applied at point-of-sale, resulting in reduced patient copays.  The situation will be further exacerbated when final 2023 DIR fee “clawbacks” are assessed during the first few months of 2024.   Pharmacists have been advised to plan for the transition by understanding their cashflow situations, and identifying opportunities to cut costs, at least in the short term.

And to be clear, the new rule does not eliminate DIR fees.  Pharmacies are still liable for the fees, with the American Pharmacists Association explaining, “PBMs will still be able to use DIR fees to extract arbitrary fees, moving them to the point of sale, in addition to extracting other unreasonable concessions from pharmacies.”  The new process will though, provide transparency, and  greater predictability, as the onerous clawback process comes to an end.  

Pharmacists can look to technology for help in mitigating the impact of DIR fees – both during the expected 2024 transition period and beyond. Several core PrimeRx capabilities, for example, allow pharmacists visibility into past – and likely future – DIR fee assessments, along with access to pharmacy financial information.  Specific functionality includes:

• DIR Fee Analysis.  The software captures historical data about DIR fees assessed by each Part D plan.  This allows pharmacy managers to easily track all prior fee payments, which provides a good indication of future fee assessments.  
• Part D Plan-by-Plan Analysis.  Since each plan assesses DIR fees based on different metrics, it’s essential to understand how each plan is structured.  PrimeRx breaks down each plan and allows pharmacies to track performance based on unique requirements. 
• Business Records Management.  The system maintains records for essentially all pharmacy operations.  This allows managers full visibility across all cost centers as a way to identify potential opportunities for savings.  Pharmacists can have immediate access to inventory costs, payroll expenditures, and fixed costs for outlays on rent, insurance, and utilities, among multiple other cost centers. PrimeRx allows pharmacists to see precisely where dollars are allocated each month.  This in turn can help identify opportunities to reduce costs, at least for the duration of the DIR fee transition.
• Report Generation.  Managers can generate reports on essentially any aspect of pharmacy operations.  Reports can be customized based on a manager’s preferred topic and reporting period.  Extensive reporting allows managers to monitor performance across all self-selected metrics and provides an opportunity to identify areas of strong performance, along with opportunities for improvement.

Pain Point #2 — Not Enough Hours in the Day. Adding Efficiency and Recapturing Valuable Staff Time

Pharmacists hardly need a survey to tell them their plates are too full, but results of the 2022 National Pharmacist Workforce Study still come as a shock, especially with regard to findings about job stress and satisfaction.  Specifically, 55 percent of pharmacists gave a “highly stressful” rating when asked about “having so much work to do that everything cannot be done well.”  And an alarming 46.2 percent said they feared that a patient would be harmed by a medication error.

When asked how they were spending their time, community pharmacists said that 72 percent of the day was spent on “patient care services associated with medication dispensing,” and 12 percent was spent on patient-related services not associated with dispensing.  

Pharmacists are spending more time administering vaccines, documenting information about services provided, consulting with patients about prescription drug coverage, providing medication synchronization services, and providing medication therapy management services.  Almost one-third of pharmacists said they spent 11 or more hours each week consulting with patients about “use of prescription drug coverage.”

Clearly, pharmacists need relief.  And technology is responding with solutions to alleviate many of the tasks that take up an inordinate amount of pharmacists’ time.  PrimeRx pharmacy software users, for example, benefit from capabilies that include:

• Workflow Optimization.  PrimeRx automates key pharmacy workflows including prescription intake, dispensing, refills, inventory management, and claims processing, among others.  

While technology will never eliminate entirely the need for human oversight, the solution dramatically reduces the time required to perform critical tasks.  A few examples include:

• Electronic prescriptions arrive seamlessly and are automatically validated and added to the dispensing queue.  
• Labels are generated, with special accommodations available for braille, large print, or other patient needs.  
• Inventory levels are automatically updated each time a medication is dispensed, and each time new supplies are added.  
• The solution automatically transmits a claim to the appropriate payer, and tracks the claim until a response is received.  
• And critically important, the solution updates patient records each time a prescription is filled, and to reflect clinical services administered, as well as pharmacist-patient discussions.
• Compliance.  Technology has automated several of the more time-consuming pharmacy compliance requirements.  
• Script Management Partners (SMP) allows pharmacies to automatically report immunization records to state/local immunization information systems (IIS).  In addition, the system identifies immunization opportunities among pharmacy patients.  The solution helps pharmacies build their immunization programs and manage compliance with mandatory reporting requirements.  Script Management Partners is affiliated with Tabula Rasa HealthCare.  
• Bamboo Health/AWARxE – This is a prescription drug monitoring program (PDMP) solution that allows pharmacists fast access to their state’s controlled substance reporting system.  Pharmacists can quickly confirm patient identification, and seamlessly report dispensing activity to their state’s database.
• Automated Refill Management – Many states regulate pharmacy automatic refill programs and require that patients have an option to confirm their preference for a medication, and to terminate participation in the program.  PrimeRx helps pharmacies satisfy this compliance requirement with its communication capabilities.  This includes automated texting/email services that generate confirmation notices about upcoming refills, and reminders when a prescription is ready for pickup. 
• InfiniTrak – The Drug Supply Chain Security Act (DSCSA) includes detailed provisions that affect the way in which pharmacy inventory is processed and managed.  Going forward, pharmacies must be compliant with technology-based requirements that establish a uniform “track-and-trace” process, and allow pharmacies to capture detailed information about all prescription medications.  PrimeRx has partnered with third-party software provider InfiniTrak, which offers solutions designed specifically for DSCSA mandates.  
• Prescription Benefit Review.  PrimeRx includes direct integration with the Real-Time Prescription Benefit from Surescripts solution.  The solution provides real-time information about a patient’s covered medications.  This in turn allows the pharmacist to determine if a prescribed medication is covered, and the patient’s copayment.  Should a medication not be covered, or require an expensive copay, the solution may suggest more appealing alternatives.  

The Surescripts solution automates this process, and eliminates time-consuming phone calls between pharmacists, plan representatives, and physicians’ offices.

Pain Point #3 — Improving Pharmacy Profitability

According to the National Community Pharmacists Association (NCPA), the average community pharmacy processed 63,228 prescriptions during 2021, with prescriptions divided almost evenly between new prescriptions and renewals.  NCPA also reports that, among pharmacies in business for at least five years, total sales will exceed $3.2 million, with prescriptions accounting for as much as 97 percent.  

In terms of profitability, analysis of NCPA data by Drug Channels Institute estimates individual pharmacy owner earnings of about $158,000 during 2020.  That figure represents a decrease from earnings of $200,000 during 2015, but a rebound from 2018, when earnings fell to $129,000.

As these figures reveal, profits can fluctuate widely from one year to the next, often with little rhyme or reason.  This can make it difficult for pharmacists to plan for future growth, establish realistic budgets, and manage their personal finances.

But technology can help.  Several technology-based solutions are available that can take the guesswork out of the pharmacy’s finances and can assist pharmacists in identifying new revenue opportunities.  A few considerations include:

• KPI Tracking and Reporting.  Key performance indicators (KPIs) allow pharmacies to home in on the economic and operational metrics that matter most, and to track their pharmacy’s performance on a regular basis.  The problem though, is the typical pharmacy takes in a tremendous amount of data each day.  The challenge is to focus on the information that is truly useful and can add insight and efficiency to pharmacy operations. 

Drug Topics suggests a pharmacist track expenses that directly affect financial performance, including inventory, payroll, and utilities.  “Any change – positive or negative – will directly affect your bottom line,” the analysis notes.

Beyond these core metrics, a pharmacist can identify other aspects of pharmacy performance.  This can include dispensing rates, staff performance, OTC product sales, point of sale activity, reimbursements, plan performance, prescriber activity, and everything in between. A pharmacy can drill down to aspects of pharmacy performance that truly affect performance and profitability, while also identifying sales laggards, and other possible opportunities for improvement.

PrimeRx offers KPI functionality that includes:  

• Extensive KPI capabilities.  The solution takes an “if you can think it, we can measure it” approach, with pharmacists able to select from a wide scope of data elements.  With just a few mouse clicks, a pharmacist can identify all KPIs that should be measured and monitored.
• Dashboard Visibility.  Pharmacists can utilize the PrimeRx dashboard feature for real-time access to performance on any and all KPIs.  A pharmacist can quickly monitor point of sale activity, for example, check volume in the dispensing queue, or determine the pharmacy’s top-selling OTC products.
• Customized Reporting.  PrimeRx includes extensive report generation functionality.  Report contents can be customized and scheduled based on a pharmacist’s preferred frequency.
• Build Your Brand as a Source for OTC and Consumer Products.  Consumers increasingly see their local pharmacy as a good source for groceries, personal care products, and even pet-related items, and savvy pharmacists are rising to the occasion.  2023 research by the Acosta Group found almost 70 percent of shoppers rely on their local pharmacy for groceries, candy, snacks, paper products and personal care items including shampoo and body care products.  “These are frequent shoppers” the analysis noted, with 58% of respondents saying they visit the pharmacy two-to-three times per month.

Expanding sales of consumer goods can be a win-win for the pharmacy.  Pharmacies increase sales and profitability while tapping into an important way to serve patients.  And for their part, customers seem poised to take advantage of the convenience of being able to purchase grocery items at the same time they pick up their medications.  

Pointy from Google is an innovative technology solution that helps pharmacies promote their consumer product inventories.  The solution allows a pharmacy’s OTC and consumer product offerings to show up in local Google search results.  Whenever a Google search is initiated for any of those products, the pharmacy will appear as a retail option.  This drives new traffic into the pharmacy and increases product sales.  PrimeRx users can integrate directly with Pointy from Google.

• Expand Immunization Services.  The Centers for Disease Control (CDC) reports fewer than half of all U.S. adults (individuals aged 18 and older) received a flu shot during the 2021-22 reporting period.  This, despite findings from NCPA that 89 percent of community pharmacies provided flu immunizations during that same period.  So while most pharmacists offered the shot, fewer than half of all adults took advantage of the convenience to get themselves immunized.  This presents a tremendous opportunity for pharmacists interested in expanding patient care services while simultaneously bringing in additional revenue.

And immunization-related revenue can quickly add up. Consider that CVS generated more than $3 billion in revenue during 2021 from COVID-19 testing and immunizations. Pharmacies can receive approximately $40 for every COVID-19 immunization administered to a Medicare patient.  

Beyond COVID immunizations, consider the experience of Seattle, WA pharmacy owner Beverly Schaefer, who was profiled by PBA Health.  Schaefer began administering flu vaccines in her Katterman’s Sand Point pharmacy back in 1996, as a way to fill a revenue gap that resulted from a decision to reject a contract from a major payer.  “We were hoping to do 300 flu shots the first year,” she told PBA Health.  It turned out though, that goal was wildly off the mark, with the total exceeding 1,200 immunizations.  As of 2019, immunizations accounted for nearly 20 percent of the pharmacy’s business, and 30 percent of profit.  

Today the pharmacy offers a wide range of “routine” immunizations including influenza, shingles, whooping cough, and COVID-19, among others.  But the pharmacy also offers a portfolio of travel vaccines, including Yellow Fever, Typhoid, and Japanese Encephalitis, which draws patients from a wide geographic area.  

Pharmacists interesting in expanding their pharmacy’s immunization offerings can access resources including the CDC, National Community Pharmacists Association, and the American Pharmacists Association.  Pharmacists can also look to their pharmacy technology system for help facilitating and managing an immunization program. Within PrimeRx, for example, pharmacists can rely on capabilities that include:

• Personalized messages.  The software identifies “at risk” patients who would benefit from specific vaccinations.  The system can automatically transmit emails and/or text messages, with a link to schedule a vaccination appointment.  The message can be as simple as: “The CDC recommends a Shingles immunization for patients over the age of 50.  Click here to schedule your vaccination.”  
• Immunization Reporting.  As discussed previously, pharmacies can access functionality from Script Management Partners (SMP) that automatically reports immunization records to state/local immunization information systems (IIS).  
• Records Management.  Patient records are automatically updated each time a vaccine is administered. 
• Claims Management.  A reimbursement claim is automatically submitted to the appropriate payer for each immunization.
• Expand Other Clinical Services.  Beyond immunizations, pharmacies are increasingly turning to other types of services, both as a way to better serve patients and tap into new revenue sources.  Research by the NCPA found that in 2022, 80 percent of community pharmacists offered medication therapy management services; 59 percent offered blood pressure monitoring; 55 percent offered compounding services; and 48 percent offered services for long-term care patients.

In a presentation to pharmacy owners, Dr. Lisa Faast, PharmD and vice president of business development for Pharmacy Development Services quantified just how lucrative some of those services can be.  

As reported by Pharmacy Times, Faast noted:  “Using existing services such as 1-on-1 consultations, educational classes, and immunizations, pharmacy owners can generate an average of $8,800 per month.”  Specific dollar amounts mentioned include:

• Flu vaccines can range from $50 to $300.
• A general wellness class could range from $50-$145 per hour/per patient.
• A smoking cessation class could generate up to $60 per hour/per patient.
• A 15-minute weight loss class could generate up to $85 per hour/per patient.
• Continuous glucose monitoring can generate up to $550 for 72 hours, with 15-minute consults generating up to $80 per patient.
• A 30-minute stocking fitting can generate approximately $200.

And the list goes on. But as beneficial — and profitable — as these services certainly can be, each poses administrative requirements that can strain staff resources.  Technology can help though, with PrimeRx capabilities that include:

• Extensive Patient Records.  In addition to medication histories, PrimeRx allows the pharmacist to maintain extensive records for all patient interactions.  This includes observations and notes following each patient interactions, along with information about a patient’s health history including immunizations, point-of-care testing, lifestyle/habits, and living arrangements.  All information is stored within PrimeRx and can be seamlessly accessed and updated.
• Medication Action Plan. Pharmacists can also create action plans within PrimeRx that can be shared electronically with the patient, along with members of the healthcare team.  Plans can be customized to include timelines for various goals, and checklists of “action items.”  The plan becomes a living document, that can be easily updated or revised as the patient’s condition warrants – and hopefully improves. 
• CPESN eCare Plans. eCare plans allow pharmacies to create comprehensive patient records that document all patient interactions and clinical services.  The plans can be exchanged among patient healthcare team members and demonstrate pharmacists’ high level of patient involvement in seeking reimbursement for services.  Pharmacies can easily create and maintain patient eCare plans within PrimeRx.  

Pain Point #4 — Medication Affordability

As pharmacists well know, medication non-adherence is a critical concern in patient well-being and a significant contributor to escalating healthcare costs.  According to the PAN Foundation, costs linked to poor medication adherence exceed $528 billion annually.  For patients, a failure to take medications as prescribed often leads to exacerbated health conditions, and even death.  While there are many reasons for non-adherence, cost is continually cited as a key factor.

2023 research findings published by Kaiser Family Foundation (KFF) found that “about three in ten adults report not taking their medications as prescribed at some point in the past year because of the cost.  This includes about one in five who report they have not filled a prescription or took an over-the-counter drug instead (21 percent), and 12 percent who say they have cut pills in half or skipped a dose because of the cost.”

Pharmacists use terms like “heartbreaking,” “frustrating,” and “infuriating” to describe instances in which patients cannot afford medications.  Indeed, pharmacists will expend significant time to help patients find a way to obtain a medication, either by identifying an alternative, or by finding a way to reduce the cost.  Those efforts have gotten significantly easier though, with multiple technology-based tools now available to help.  A few examples include:

• eVoucher and Denial Conversion Services. PrimeRx addresses medication affordability with solutions that address claims denials and excess copay amounts.  Together, these solutions help pharmacists ensure their patients leave the pharmacy with the medications they need, at a price they can afford.
  • The eVoucher services solution operates at point of sale.  The software automatically identifies and applies manufacturer co-pay coupons, providing immediate relief to patients in the form of reduced out-of-pocket costs. 
• Denial Conversion Services.  Prime Rx pharmacies can ensure patients receive their preferred medications, while also generating revenue by participating in Micro Merchant Systems’ Denial Conversion Services program.  The program allows pharmacists to provide patients with their prescribed medications – even if the claim has been rejected by the payer.  

The program converts a denied claim to “paid” status, thereby allowing the pharmacy to dispense the medication.  Micro Merchant Systems, the company behind PrimeRx, reimburses the pharmacy for the cost of the medication and also pays the pharmacy a transaction fee.  Denial conversion offers a win-win solution for pharmacies:  Patients are able to obtain their preferred medications, while pharmacies benefit from increased revenue. 

• Prescription Benefit Review. As discussed previously, PrimeRx includes direct integration with the Real-Time Prescription Benefit from Surescripts solution.  The solution allows real-time visibility into a patient’s drug formulary as a way to identify (a) if a drug is covered and (b) the copay amount for that medication.  If a drug is either not covered, or is too expensive, the solution may offer up to five therapeutic alternatives.  

Pain Point #5 – Inventory Costs

A popular textbook titled Pharmacy Management for all Essential Settings notes that few pharmacy management functions are as critical to store profitability as inventory control.  “A pharmacy’s inventory represents its single, largest investment,” the authors wrote. “Consequently, no other asset has the potential to devastate a pharmacy as much as poorly controlled inventory.”

The goal of every pharmacy, of course, is to strike the right balance between demand and cost.  Pharmacies want to have the right products at the right time, and minimize the risk of having unused medications expire on the shelf.  But without a crystal ball to foresee actual needs, inventory management can sometimes seem like a game of chance.  While a pharmacy can anticipate demand for top-selling medications including amoxicillin and Lipitor, the high cost of other drugs cause most pharmacists to limit supplies of slower-moving medications.  

Pharmacies also face the challenge of managing multiple inventories and having real-time access to business records for each inventory. This has become increasingly important as community pharmacies have increased participation in federal 340B Contract Pharmacy Services.

Pharmacists can look to technology though, for comprehensive inventory management assistance. As the following PrimeRx capabilities make clear, technology can not only provide visibility into inventory holdings, but can facilitate the ordering process, help anticipate demand, and facilitate multiple inventory management.

• Demand Forecasting. Pharmacists can analyze sales and transaction records to anticipate demand for OTC products and medications. Access to historical sales data can help guide pharmacists in determining inventory levels for in-demand products, and by identifying sales laggards, and costly medications that are likely to go unused.
• Perpetual Inventory for Visibility and Automatic Reordering. The system’s comprehensive, real-time tracking capability allows pharmacists to know the precise content and value of their inventory at any given time. This includes medications stored in a pharmacy’s refrigerator and on the shelves.  Once the quantity of a medication reaches a pre-determined level, PrimeRx will automatically submit a reorder request.
• Compounding Ingredients. Inventory levels are adjusted automatically to reflect medication quantities used in preparing compounded medications.
• Patient Communication. Pharmacists can avoid the risk of a high-cost medication going unused by reaching out to a patient prior to making the purchase, to ensure the medication is needed. PrimeRx includes extensive 2-way communication features that pharmacists can use to generate patient texts and emails.  The patient can quickly respond, which can help guide the pharmacy in its inventory planning process.
• Price Comparisons. PrimeRx provides direct access to multiple wholesalers, which allows pharmacies to compare costs before an order is placed.  Depending on a pharmacy’s geographic location, the software also integrates with multiple group purchasing organizations, which allows access to medications at reduced cost.
• Drug Supply Chain Security Act Compliance. The federal DSCSA mandates several new requirements with regard to pharmacy inventory practices, as a way to improve visibility and traceability within the nation’s prescription drug supply chain. Among the law’s many provisions, a pharmacy must have in place a technology system that meets new “track-and-trace” requirements, including easy capture of detailed information for each drug in the pharmacy’s inventory. PrimeRx has partnered with InfiniTrak, a leading provider of software designed specifically to address DSCSA provisions.
• Multiple Inventory Management. Pharmacies can seamlessly manage multiple inventories within PrimeRx. The software designates a “bucket” for each inventory, with separate buckets configured to contain and manage different inventories. Inventory allocated to a “340B Bucket,” for example can exist alongside other inventory buckets, but will not be intermingled.  Medications are deducted — or added — to the appropriate inventory, with report generation capabilities for each bucket.

Conclusion

As pharmacists continue to adapt to changes in the pharmacy setting, namely their increased role in patient care, one thing seems certain — more changes are on the horizon. Consider, for example, findings from a 2022 survey by Wolters Kluwer, which found “three out of five American health consumers (61 percent) can envision most primary care services being provided at pharmacies, retail clinics and/or pharmacy clinics instead of going to a primary care provider.”

Ready or not, pharmacists are poised for an even more important, more visible role in patient care. This, no doubt, will mean a whole new set of challenges and pain points. But as pharmacists accept these increased responsibilities, technology will be on hand to help solve problems, add efficiency, and ensure optimal patient experiences.

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