The exam of pharmacy technician will be towards 200 described drugs and the formulas, which are used for their conversion & how to make the descriptions. If you not know the math well you should make your practice using the different capacities and measuring the weights. You should recon that you should also know your familiarity with the names of manufacturers, their generic names, and the commonly known names of these medicines. You can use the manual guidebook, software’s used for simulation, and you can either attend a running class or on the other hand you can appear in the exam without any preparation. You should be more attentive about the use of algebra, how to make the conversions, use of mathematical formulas, and problems related to words. It is right that it can be very difficult if you haven’t use them or practiced them in a long period of time. You will have to perform the same kind of activities so it is advised to you to be ready for all when the time will come so you should continue to make the practice for using them. You can use the word of CPHT with your name when you will finalize the pharmacy technician examination.

When you will be a pharmacist with a certification you will have access to more working options as well as you will be awarded with more competitive positions. According to the PTCB policy being a pharmacy technician with the required certification is based on the following regulations. If you cann’t met the requirements of the federal government you will be without awarding the certificate at all. The same behavior will be with you if you found guilty of doing some misuse. If you also not cooperate with the agencies in the investigation process you will also be without this certification. If you want to receive this pharmacy technician certificate you should abide by the very strict rules and regulations of the PTCB certification awarding board. Very truly, you are blessed with the power to give someone suffer & though kill.

In the pharmacy tech examination you will be offered a maximum of 90 questions relevant to the pharmacy to be covered within 2 hours time about the details of the drugs and their affects. For the patient help very quick and short references for these drugs are used. The laws about pharmacy will be given attention in this examination. The federal government also implements the laws about these prescribed drugs. You will surely find some calculations work and how to make the conversions between the various units of making the measures. The conditions will be given to you and it will be examined about your conversion techniques based on the each and every situation.

There will be 90 questions in the pharmacy technician examination that will be based on different medicines and how to make the calculations between these medicine measurements. You will have a time of 2 hours and a sum of 90 questions will be asked. The following areas will be covered thoroughly in this exam. The first step of the basic importance that is about 66% of the total exam, is to provide all the necessary help to the pharmacist & how he should serve the patient he is dealing with. This will play a very vital role in your daily job routines being a technician. You have to perform your services on the daily routines how to serve them with the best. If you want for this to be fine your communication & interpersonal skills are of much importance. The second part will mostly pay more attention to the issues of inventory & how to make the maintenance of the use of medicines.

Being a technician you offered be the in charge of the large inventory of medicines so you need to be blessed with required organizational skills. In the cased if the drugs are without any labels, misplaced or when demanded you cannot find them, you can very surely understand that bad condition. You need to be very active in finding the drugs when you want to be a pharmacy technician professional. The last area of importance will be on the administration of the pharmacy technician examination and it will be based on the 12% of the examination. You have to make the payment of one hundred & twenty nine dollars. As the demand is increasing for the medicines, its price is likely to increase in the next years. You can appear in the exam on the basis of phone, online or emails. You can have the three chances if you cann’t pass in the beginning. It is best for you to make the best of preparation if you want to pass it in the first reply. Your certification must be renewed within the 2 years time.

There are people who are starting to wonder if all the good things they hear about pharmacy technician jobs are true. Type in pharmacy technician jobs on your internet search engine and you’ll read about how high the demand and that the need for this job will continue to grow in the coming ten years, or so. If that is so, why is it that there are those who couldn’t get be in this profession even though they are qualified for the job openings because they’re finished a training program. Now, there are individuals in this profession that are beginning to wonder if the certification they’re carrying is as important as what those internet articles are claiming.

Many people who signed up and finished pharmacy technician training courses assumed that after doing so, pharmacies and other companies looking for applicants will come knocking at their doors. There are also some people who were certified by either PTCB or ICPT that are in the same boat as the previously mentioned group of people that believes getting pharmacy technician jobs is that easy. Even if you’re already certified, you still have to go out and present yourselves to potential employers. Some experienced jobseekers will even tell you that job hunting is a job in itself.

The question for now, I guess, is how to start looking for such jobs, but the better question IMHO is where to look. While we’re on the subject, if you don’t know what IMHO stands for (In My Humble Opinion), that only means you’re also not aware of the many advantages that the internet can give your career. IMHO is a common abbreviation used by experienced users of the internet and they are very well aware also that you can find many things on the internet. Most job ads for this career can be found on the internet because companies that have needs for that position are posting them online. Try searching for these companies’ websites because that’s where they usually post the list.

If you’re still considering signing up for a training program and don’t know yet which school to enroll in, consider the school that have a job placements assistance program for their graduates that will help them find pharmacy technician jobs. Obviously, that will be a great help when you’re just starting your career. You can also join professional groups like the NPTA, a society for pharmacy techs. Professional groups like the NPTA usually have programs and special events exclusive only for group members where they can find potential employers or help them become aware of the latest developments in the said field.

The worst thing that you can do is be discouraged and give up finding a job is when you hear other people failing to land a job of their own. Some people can’t get themselves hired for this profession because of a lot of possible reasons. According to the US Bureau of Labor Statistics, almost a hundred thousand new pharmacy technicians will be needed in the next decade, and that means the job opportunities will be out there. Finding a job is not that easy, you have to work hard for it, too but eventually, you will find that one job that you really like.

Is it worth becoming a pharmacy technician? First of all, I can’t answer that for you. What I can do instead though is a give you a general overview of some of the good points and bad points as I see them and then let you make up your own mind.

If all else fails, ask around. You probably know some people who are pharmacy technicians. In turn, they’ll know five other people who are pharmacy technicians and so on and so forth. Just continue down the line and pay attention to recurring themes.

Positives of Becoming A Pharmacy Technician

Quickness: Sometimes I cringe I to think about all the time, effort and money I put into pharmacy school. Six years. Thousands of hours. Tens of thousands of dollars. Of course, the payoff has been pretty nice. At least for most people it would be considered nice. But there were times, oh were there times, when you thought about packing it in and giving it up because six years seemed so far down the road. And that was if you got through without any problems.

I know a fair amount of pharmacists who took longer. Sometimes up to ten years. A decade of your life.

But if you want to learn how to become a pharmacy technicians it’s a lot different. In my experience you can go from cold, off-the-street, don’t know a thing about pharmacy person and within ninety days be a functioning and ready to be certified technician. Within a year you could be certified and head technician making $13 or $14 an hour. Not a princes sum, but for a lot of people it’s nothing to sneeze at.

All this was done in a fairly quick amount of time with most (if not all of it) being done on-the-job without having to dole out your hard earned money or time for college courses.
Surroundings: My dad used to harp on doing something that you didn’t have to work outside. Imagine…warm during the winters and cool during the summers.

Well, he’s right. Not to mention that most employers will give you pretty decent benefits. I still smile when I look outside in August when I see people struggling in the 97 degree heat while I’m comfortably working in an air conditioned pharmacy.

Speaking of surroundings, you’re also not beating your body up to make a buck. No strained backs, sunburns, broken fingers and the like. Of course, you can end up on your feet in pretty much one spot for hours on end – but every job has trade offs.

Benefits: Most of the time when you are a technician you’ll be working for larger corporations. And, as such, they are used to paying benefits for their employee’s. Sometimes the benefits are extraordinary.

For example, one of my employers (in mail order at the time) offered free health care insurance. And, not just for you. But your whole family. Didn’t matter if you had one kid or ten. You didn’t pay a dime.

Also, they had a package set up that if you worked for them until age 55 and had a certain amount of years experience you could have your health insurance paid for in retirement until you died. They also offered stock options and bonuses.

The point is that any job in the medical field right now can be a good place to be because they are hurting for workers and the need, on the consumer side, for medical care never goes away.

Negatives of Becoming A Pharmacy Technician

Won’t Get Rich: While you can make some decent money as a pharmacy technician you’ll likely never get rich doing it.

The highest I’ve ever seen a technician paid in my area was $20 an hour. Good money – particularly for no formal education. But that’s probably about as high as you’ll see.

Animosity: This is kind of a touch subject for some technicians because they feel like they are being picked on. But that’s not what I’m trying to do. What I am trying to do is point out that when you are a pharmacy technician you are basically a helper to the pharmacist. After a while some technicians see that pharmacists are ‘just checking’ prescriptions and that they do most or all of the work.

First of all, you will work with some bad pharmacists from time to time. Maybe they do make you do more than your comfortable with. Maybe they are jerks. It could be any number of things. But you have to get over that. Being subordinate to the pharmacist is part of your job – and your job description.

Other times technicians feel that pharmacists don’t really do anything that special or complicated and that they should be paid more. This is the group I struggle with the most as I can promise you that pharmacists take all of the responsibility for everything you do. That’s why they are paid three times more than you. If you screw something up and the pharmacist doesn’t catch it guess who gets a call from the patient’s attorney?

Yep…the pharmacist. Not the technician.

If that’s hurts some feelings so be it. But it’s the truth.

So, does that seem like a lot of downside to you? It shouldn’t.

Becoming a pharmacy technician is a relatively easy field to get into. You get paid decent. The demand will always be there. And, if you prove your worth, you can make it into the $20 an hour range. Depending on where you live that may or may not be a lot of money. But, considering that there are some people I know who went to college for five years for a worthless degree and are now qualified to ask, “do you want fries with that” for $8 an hour it seems like a pretty decent trade-off.

Besides, becoming a pharmacy technician may help you decide that you want to go do something more or do something more. If you train on the job all that cost you to realize that was some of your time. No money. You can’t say that about a college degree.

And, believe it or not, I know doctors who only realized they never wish they would have become a doctor until their second year of residency. Ouch.

In the United States, those individuals that engage in careers in pharmacies are considered to be the leading experts regarding medicine. This makes the opportunity for acquiring a job in pharmacology very accessible for many individuals. This career is considered to be one of the fastest growing careers in the industry of healthcare. In this article, you will be introduced to careers in pharmacies.

Today, many different types of doctors make a diagnosis on the many ailments that people and animals may experience. One of the steps that can help humans and animals recover from the ailments that they experience is by participating in prescription therapy. Numerous healthcare professionals write prescriptions. These include general doctors, pediatricians, psychiatrists, optometrists, dentists, and even veterinarians. The pharmacy is the location where the prescriptions, or drug orders, are filled and then dispensed to the proper individuals.

In a pharmacy, you will normally find two types of jobs. That of the pharmacist and that of the pharmacy technician. You may also find pharmacy assistants or sales associates in the pharmacy as well. These individuals must take the prescription, decipher the handwriting on it, make an overall interpretation of the prescription, select the medication from the stock, count out or measure the prescription, and make an appropriate label for the medication.

In addition to the above task, the patient must receive counseling on the medications that they are going to be ingesting. It is also the duty of the individuals who have careers in pharmacies to maintain the records of the customers. Insurance information must also be gathered, confirmed, documented, and recorded so that the companies may pay their share of an individuals cost that are associated with medications. This profession can be quite stressful due to the laws and liabilities that are dealt with. This is why careers in pharmacies require an individual to be properly educated.

Pharmacists

Pharmacists are considered to be the “drug information specialists”. These are the most highly trained individuals in the pharmacy. While pharmacy technicians and assistants may have the same basic understanding as a pharmacist on many things, the pharmacist is the one with the official educational background and certification to accurately perform their duties within the state that they practice. These individuals verify the prescriptions that are filled prior to being given to the patient. There are also responsible for discussing the medication with the patients.

In addition to the above information, a pharmacist may find that they are in a position where they must offer advice to doctors and other professionals on certain kinds of medications. Some of these individuals have the ability to write prescriptions. However, the ability to perform this task is directly related to what the laws outline in regards to the specific area in which that pharmacist works.

Individuals who are interested in acquiring the ability to become a pharmacist must attend college. Those that attend college for four to five years are issued a Bachelor of Science in Pharmacy. Once this is acquired, an R.Ph will be added to the end of the name of the individual. There is also a Doctor of Pharmacy Degree that many choose to obtain in the field. These can be obtained once the BS degree is obtained. Individuals may elect to simply enter an add on program that enriches their current degree.

The following classes outline the coursework that pharmacists are generally subjected to when acquiring a degree in pharmacology:

1. Writing

2. Sociology

3. History

4. Ethics

5. Communications

6. Psychology
7. Advanced Math Courses

8. Biology

9. Chemistry

10. Medications and Drug Courses

11. Pharmacology Machinery

12. Pharmacological Calculations

This particular job pays an average of $50,000.00 – $175,000.00 annually, depending on the size of the area in which the individual works, the demand, and the educational background achieved in the areas related to the profession.

Pharmacy Technicians

Pharmacy technicians play a very important role in pharmacies in the United States and Canada. These individuals normally work to greet the customers that visit the pharmacy and answer telephone calls. It is very common for the pharmacy technician to deal with customers, insurance companies, and doctors directly. They assist in the filling and dispensing process within the pharmacy as well. Operating computers, understanding the technical aspects of the inner workings of the pharmacy and dealing with pharmacological calculations and measurements is a common task.

A certification is normally required to become a pharmacy technician. The most common classes for an individual in this career include:

1. Regulations for Drug Development

2. Drug Manufacturers

3. Medical Terminology

4. Pharmaceutical Calculations

5. Dosages forms and Administration

6. Prescriptions

7. Pharmaceutical Dispensing

8. Anatomy and Physiology

9. Basic Chemistry of Drug Molecules

10. Over-The-Counter Drugs

11. Package Inserts

12. Drug Emergencies

The average pharmacy technician can receive their education in less than two years time. The average pay rate for this position ranges from $12.00 – $18.00 per hour depending on the location of the pharmacy and the demand for certified pharmacy technicians.

Pharmaceutical Companies

Biogen Idec – Canada

Amgen – Canada

MedImmune – Canada

Chiron Corporation – Canada

Millennium Pharmaceuticals – Canada

Johnson & Johnson – United States

Pfizer – United States

Abbott Laboratories – United States

One of the current trend issues in medical fee dispute resolution circles is pharmacy reimbursement. Niche pharmacies have entered the Texas workers’ compensation market. These pharmacies only market and provide services to injured workers. They do not fill prescriptions for non-workers’ compensation patients. Some are national retailers to injured workers, and others are more local, servicing their surrounding communities. Regardless of their size and the scope of their market(s), they are all dealing with one common fee dispute in Texas – a proxy for the pharmacy’s usual and customary fee.

The maximum allowable reimbursement (MAR) for prescription drugs is set by Division Rule 134.503(a). Under the Rule, the MAR is the lesser of:

1. The provider’s usual and customary charge;

2. A formula based on average wholesale price, a modifier and a dispensing fee;

or,

3. a negotiated or contract price.

If there was a negotiated or contract price, then there would be little need for litigation over a single prescription bill. The recent cases being set before the Division are disagreements over a pharmacy’s usual and customary charges. The pharmacies are billing an amount greater than the formula-based MAR so that the formula-based MAR is paid in every case.

There are many factors in establishing the price of a product – some unique to the workers’ compensation system. In Medical Dispute Resolution case number M4-02-5033-01, the pharmacy argued that it had to factor into its price the unique aspects of: verification that claims relate to compensable workplace injuries, identification of insurers providing coverage and their adjustors, the preparation and submissions of manual claims forms, verification of eligibility for compensation, and the extension of credit pending payment by insurers that is not required until sixty days after the submission of “clean claims.” Considering that the formula-based MAR uses modifiers ranging from 1.09 to 1.25 with only a $4.00 dispensing fee, it can be easy to see how usual and customary prices can be established that exceed the formula-based MAR.

If these cases involved large pharmacies with high volume non-workers’ compensation services, then the operating costs of providing workers’ compensation-related services would be offset by the efficiency and volume of the non-workers’ compensation-related services. Prices would probably tend to be lower in that scenario. But that is not the case with these niche pharmacies marketing only to injured workers. The only way they can get reimbursement is to navigate complex reimbursement systems that require more sophisticated knowledge, greater manpower and longer delays of payment than non-workers’ compensation systems.

Regardless of the justification (or lack thereof) of the prices established by these niche pharmacies, it is not why the pharmacy charges a particular amount, but whether it can establish that it does usually charge a particular amount that is important. Rule 134.503(a) specifically provides that one of the comparison measures for the selection of the MAR value for prescription drugs is the provider’s usual and customary price. The question is not whether the usual and customary price charged is justified. The question is whether the price charged is in fact usual and customary; is it the regular price charged by that provider?

This is the crux of the dispute in these cases. In non-workers’ compensation situations, many of the larger national pharmacies have negotiated contract prices well below the Texas formula-based MAR. These niche pharmacies that only provide services to injured workers have not. So insurance companies are seeing workers’ compensation providers obtaining a higher reimbursement for a particular prescription than it usually pays in non-workers’ compensation situations. This led to attempts to curb these niche pharmacy’s fee reimbursements.

There is only one Medical Contested Case Hearing so far on this issue, reported as Medical Contested Case Hearing Number 10169, and it went through the system as Tracking Number M4-07-4069-01. In this case, the carrier made a partial reimbursement and urged two main reasons why additional reimbursement should not be paid.

First, the carrier had to make some type of reimbursement as there was no dispute over medical necessity. The carrier had negotiated a contract price with another pharmacy or pharmacy clearing house and paid the amount it would have had to pay under that contract. The carrier then argued that the clearing house’s price is a good proxy for the niche pharmacy’s usual and customary price simply because the clearing house has contracted with other pharmacies to pay less than the niche pharmacy’s price. So the carrier argued that the usual and customary price it pays should be the measure for MAR, not the provider’s usual and customary charge.

Secondly, the carrier attempted to use Texas Labor Code Section 415.005 as a bar to additional reimbursement. That section provides that a health care provider commits a violation if the person charges an insurance carrier an amount greater than that normally charged for similar treatment to a payor outside the workers’ compensation system, except for mandated or negotiated charges. The carrier argued that if the pharmacy cannot show what it charges outside of the workers’ compensation system, then it has not proven its usual and customary charge and would not be owed any additional reimbursement. Being a niche pharmacy, only providing services to injured workers, the pharmacy could not show charges outside of the workers’ compensation system. Of course this begs the question: why did the carrier pay anything at all in the first place? If the argument is that (1) a failure to prove usual charges outside of the workers’ compensation system means there is no usual and customary charge established, (2) which means there can be no determination of whether usual and customary or the formula-based MAR is the lesser charge, so (3) no reimbursement is owed, then no reimbursement would have been owed in the first place.

Judge Cole wrote an opinion that tracked the plain language of the law. He found that there is no provision requiring the pharmacy to establish the usual and customary charge for the prescriptions filled for customers outside of the workers’ compensation system if the pharmacy does not fill prescriptions outside of the workers’ compensation system. Likewise, under the Act and Rules, there is no provision allowing a carrier to substitute a proxy’s charge as the usual and customary charge. There are only three methods to establish the proper reimbursement under the Rule. Allowing a carrier to make up a fourth method is not one of the three methods. The only requirement under Rule 134.503(a) is that the pharmacy establish its own usual and customary charge. Some other pharmacy’s usual and customary charge is not relevant.

Texas Labor Code Section 415.005 is being interpreted to be a comparison of one provider’s own charges inside and outside of the workers’ compensation system. It is not a measure of one provider’s charges inside the system to other provider’s charges outside of the workers’ compensation system. This is a significant distinction in this opinion.

Additionally, Texas Labor Code Section 415.005 addresses the multi-jurisdictional issues that arise with national workers’ compensation pharmacies. These pharmacies may charge a different rate in some states than others because of varying fee schedules. For instance, in New Jersey there is a law forbidding a health care provider from demanding or requesting any payment in excess of those permitted in the fee schedule (N.J.A.C. 11:3-29). That system is not like the Texas system that allows a usual and customary billing that is reduced to the proper fee schedule amount by the insurance carrier. Section 415.005 protects providers in Texas who also provide services in other states for a mandated fee – the lower fees billed in other states due to fee guidelines do not affect the calculation of the Texas provider’s usual and customary charges.

The end result is that we now know that the Rule means what it says: if a pharmacy can show that it has billed its usual and customary charge for a prescription drug, then it will be paid that amount, or the formula-based MAR, whichever is less.

I have been writing articles on why and how to become a pharmacy technician, but some recent feedback has made me realize I left out the obvious. What is it that pharmacy technicians do in a pharmacy. Most people figure they help the pharmacist enter prescriptions and count pills. This is true for an outpatient pharmacy, also called a retail pharmacy, but there are many roles for pharmacy techs in healthcare. The rest of this article will discuss the job description of pharmacy techs in a retail or community setting, and provide a bulleted list of tasks. Future articles will cover different pharmacy settings for pharmacy techs and the job descriptions and tasks associated with them as well.

Community/Retail Pharmacy: I have worked retail, and I prefer other settings; however, it is where a large percentage of pharmacy technician jobs are found. What a pharmacy technician can do is determined by the state they work via state laws and rules. In general, technicians cannot provide clinical information to patients or be the final check for prescriptions. In some states, technicians are allowed to provide information on over-the-counter (OTC) medication (ie, medications that do not require a prescription, such as, acetaminophen and ibuprofen). Specific roles that pharmacy technicians can have in a retail pharmacy include: general technician, lead technician, buying technician, compounding technician, and billing/insurance technician. In most pharmacies, pharmacy technicians are general technicians with some of the above listed skill sets. When you go into a larger and busier pharmacy, you can actually have job differentiation where people have assigned specialized tasks (based on the needs of the pharmacy).

Pharmacy technician tasks for retail pharmacies include, but are not limited to:

Collecting patient information (insurance and personal information as needed)
Entering and processing prescriptions in the computer system
Filling and selling prescriptions
Requesting refills from doctor offices for patients
Compounding medications that are not commercially available
Ordering medications
Restocking shelves
Answering the phone
Working with insurance companies on approving payment for certain medications
Maintaining the cash register and conducting accounting functions
Retail pharmacies tend to get a bad rap from within the pharmacy profession. Although I prefer hospital (which will be the topic of the next article), I enjoyed my time in a retail pharmacy. I was able to get to know the customers (I like say patients) personally. It is a great feeling when a long-time customer comes to the pharmacy and you know them by name, maybe a little about their family, and most important you know their medical history. Because of this relationship, you are able to ensure that the patient’s medication regimen is optimal, as a technician you can help determine if there are generic alternatives to medications prescribed in order to help the patient save money.

In summary, retail pharmacies are the most common type of pharmacy, and therefore the place where the majority of pharmacy techs are employed. Due to an increasing elderly population (thank you baby boomers), retail pharmacies will continue to increase in demand. If you find a pleasant retail pharmacy to work in, and good staff to work with, a retail pharmacy technician position can be a positive experience.

Is What We Knew Last Month Now History?

Who reading here believes that what we thought we knew last month is now history? In our environ of rapid, almost immediate (if not daily) changes, how will these challenges cause our customer service and patient-oriented adherence activities to change?

Being successful as a pharmacy owner or hospital outpatient pharmacy director today demands constant awareness of the proposed national mandates… and more importantly… immediate understanding of the impact on the pharmacy’s ROI (return on investment). Knowing which low-level profitable pharmacy workflow activities demand the most time to complete can allow pharmacy workflow adjustments so less time is spent on these human resource consuming efforts.

These understandings can be used to improve ROI success… even though they are unique to each and every pharmacy. Will this knowledge support establishment of more available time that can be used in the high-level profitable areas? It can when selected pharmacy workflow functions are re-assigned and enhanced patient education occurs. A major result is enhanced medication adherence by patients.

Challenges to ROI Come From Everywhere

Today, challenges to pharmacy ROI are more frequent with many a result of the virtualization trends that are occurring. What do you know about mAdherence (mobile adherence) and mHealth (mobile health) and how they can impact ROI?

It’s well known that the solution to any problem lies at the base of that problem. With this in mind, why not accelerate implementation of mAdherence and mHealth efforts to support awareness of the high-level profitable pharmacy workflow activities? Which elements or steps of pharmacy workflow and patient education for medication and therapy adherence can be categorized low-level profitable or high-level profitable? No doubt the categorization will be unique to each pharmacy operation, yet there are some similarities.

Defining the Time-Takers, the Time-Savers and the Money-Makers

Rather than abruptly considering Time-Takers as “aliens invading our pharmacy workflow planet”, most pharmacists understand several time-taker type activities fall into two categories: pharmacy workflow and secondly, patient education/medication and therapy adherence activities completed by the pharmacist and staff. Within traditional pharmacy workflow, simple casual observation suggests the selection/counting/filling/verification and prescription adjudication areas are the largest Time-Takers. It is also easy to consider the effort (and time) needed to complete patient education and adherence activities as another Time-Taker.

But which Time-Savers are available to challenge these Time-Takers? How might the Time-Savers convert Time-Takers into Money-Makers? The Time-Taker activity of selection/counting/filling/verification activity can be easily and quickly converted. The answer: Automated Pharmacy Dispensing. Numerous systems for automated counting and automated dispensing are available in today’s automation environ. Only certain of these systems however can eliminate as many as 7-9 of the necessary steps involved in the selection/counting/filling/verification sequence. Prescription adjudication, insurance problem solving and therapy management adjustments by the pharmacist… on the other hand… can also often be another time-consuming effort (opportunity?).

Some independent pharmacies and select hospital outpatient pharmacies dedicate senior pharmacy technicians to solve potential adjudication issues or care transition needs in advance of the dispensing and education/adherence process. Upcoming fills for any individual can be pre-screened for possible insurance issues, combination with other forthcoming refills, pre-authorization of payments for medication therapy management and other health-supporting activities (immunizations, body mass, etc.).

Working through whether or not a patient has an insurance payer that will support medication therapy management efforts before any discussion with the patient saves considerable discussion time later, allows them to understand the complexity of the activity and diffuses patient aggravation.

Are Pharmacy Case Managers An Answer?

The concept of pharmacy-completed, patient-specific, healthcare “case management” approaches are new to the profession. With support from full-time (as opposed to part-time) senior certified and registered pharmacy technicians responsible for specific patients, these technicians can work with the patient/customer supporting the advance of the patient’s health improvement. These approaches are not unlike those being using by hospital outpatient pharmacies in their care transition efforts for discharged patients.

Incorporation of mAdherence (mobile adherence) and mHealth (mobile health) through the use of specifically designed smart phone apps with this case manager approach converts the Time-Takers into Time-Savers enlarging Money-Maker opportunities. The patients subsequently feel they are a family member of the “pharmacy” and have a pharmacy medication/therapy home.

Although it would first appear most Time-Takers might never be considered Money-Makers, the use of adjustments in approach to effecting traditional pharmacy workflow and patient adherence activities can actually elevate these Time-Takers into Time-Savers and Money-Makers.

Not a day goes by when our email inboxes do not fill with advertisements for prescription drugs. Many of these emails promise to deliver drugs of all classes by overnight courier without a prescription. While there are legitimate online pharmacies, and the practice of telemedicine or cyber-medicine is gaining acceptance, this change in the way medicine is being practiced is rocking the foundations of the medical establishment. Being able to consult a doctor online, and obtain prescription drugs delivered to your doorstep by UPS has broad social and legal implications. The Internet facilitates making drugs available to those who may not be able to afford to pay US prices, are embarrassed to see a doctor face-to-face, or are suffering from pain, the treatment of which puts most doctors in direct conflict with the ‘war on drugs’ but on the other hand there is the question whether these pharmacies make drugs available to recreational drug users without the oversight of a licensed medical practitioner.

The Need for Alternatives

Medical care in the US has reached a point where it is expensive and impersonal which has caused the consumer to become generally unsatisfied with the medical establishment as a whole. Examples include the huge differences between the cost of drugs in the US and Canada, long wait times in US pharmacies, and poor service in general. Perhaps realizing this, US customs appears to tolerate the millions of Americans that visit Canada every year to buy their medications, as for the most part, these ‘drug buyers’ are elderly American’s that can’t afford the high cost of filling their prescriptions in the US.

Rather than to travel to Canada or Mexico millions of Americans are now turning to the Internet for both their medical needs. Telemedicine (or cyber medicine) provides consumers with the ability to both consult with a doctor online and order drugs over the Internet at discounted prices. This has resulted in consumers turning to online pharmacies for their medical needs, and in particular pharmacies with a relationships with a physician, which allow the consumer to completely bypass the traditional brick and mortar pharmacies, with the added benefit of having their physician act as an intermediary between the consumer and the pharmacy. According to Johnson (2005) this is as a result of consumers becoming very dissatisfied when it comes to dealing with both brick and mortar pharmacies and medical practitioners. As Johnson, notes, “Consumers are more likely to know the name of their hairdresser than their pharmacist.” When Johnson (2005) rated the various professions within the health care system, he found that pharmacists had the lowest interaction with their patients than did any other group. Today, as a result of this “consumers are buying 25.5 percent of their prescriptions online, opposed to 13.5 percent of which are picked up at a brick and mortar pharmacy” (Johnson 2005).

Drugs and Society

What has brought so much attention to online pharmacies is that it is possible to obtain just about any drug without a prescription online. Many of these prescriptions are for legitimate purposes purchased through an online pharmacy because the buyer is too embarrassed to visit the doctor or for other reasons including the unavailability of FDA approved drugs to the consumer. These drugs may include steroids that due to their misuse and being classed as a classed a category three drugs, are seldom prescribed by physicians. These drugs have a useful purpose to those suffering from any wasting disease such as AIDS, they also play a role in ant-aging (FDA, 2004).

The Doctor Patient Relationship

Today a visit to a doctor is generally brief, much of the triage it is done by a nurse or a nurse practitioner with the doctor only dropping in for a few minutes, if at all. In many cases the patient is seen by a nurse practitioner. One of the arguments against telemedicine or perhaps a better term is cyber-medicine, is that the doctor does not have a physical relationship with the patients and thus is in no position to make a diagnosis, and thus can not legally prescribe drugs.

Ironically when one compares the work up that one has to go through to consult with an online physicians and compares this to a face-to-face visit with a brick and mortar doctor, one finds that the online physician, in many cases, has a better understanding of the patient’s medical condition than does the doctor who meets face-to-face with the patient. In most cases before an on-line a doctor prescribes any type of medication they insist on a full blood workup they may also require that one has additional tests performed, for example.

The AMA, the federal government, and various states claim, however, that it is illegal for a doctor to prescribe drugs without a valid doctor-patient relationship. While there are no laws at present that outlaw online pharmacies, various states have enacted legislation, or are in the process of enacting legislation to prohibit a doctor from prescribing drugs to a patient that they have not seen face to face. Some states also require that the doctor that prescribes the drugs be licensed in their state. This alone could hamper the development of cyber-medicine. According to William Hubbard (2004), FDA associate commissioner “The Food and Drug Administration says it is giving states first crack at legal action, though it will step in when states do not act” (FDA, 2004).

Internet Pharmacies

The reason that email boxes around the country fill up with offers to supply drugs of all kinds, at reduced prices, without prescriptions, and more is because people buy them as the billions of dollars the drug companies are making each year attest to. The Internet has become the drug store of choice for many.

Categories of Internet Pharmacies

Internet pharmacies are generally acknowledged to be comprised of the following five categories:

Internet pharmacies can be divided up into five different categories, as follows:

Licensed online pharmacies with a no medical affiliation.

Licensed online pharmacies with a medical affiliation

No record online pharmacies (NRP)

International online pharmacies (IOP)

Licensed compounding pharmacies

The licensed online pharmacies with a no medical affiliation are of course Drugstore.com, CVV, and others. They all require a prescription from a licensed doctor that the patient has a doctor patient relationship with. The prescription can be called in by the doctor.

The licensed online pharmacies with a medical affiliation often depend on a broker. The broker collects your medical information, and then assigns your case to one of their networked physicians. Many of these networked physicians are willing to prescribe pain killers as they believe that it is only through the use of these drugs that some people can live a harmonious life.

A Government Accountability Office (GAO) Committee on aging held in June 2004 found that “Unlicensed international pharmacies do not require a prescription, and are generally located off shore.” No prescription pharmacies can be found all over the world. Many of these sites have come under controversy as in some cases all it takes to have that prescription delivered to you by next day air, is to fill out a questionnaire online.

A study conducted by Henkle in 2002 to ascertain how easy it would be to obtain drugs over the Internet found that “37 of the 46″ pharmacy required a prescription from a licensed doctor. The emphasis was on the prescription and not on the doctor. Henkle (2002) in fact notes that some sites offered to recommend a doctor.” Henkle (2002) was able to obtain prescription drugs from nine sites outside the US during the study, without a prescription.

Online pharmacies with a doctor affiliation

There are a number of online pharmacies, with a medical affiliation is that take great pain to differentiate themselves form unlicensed overseas pharmacies. These pharmacies, stress that they are “American based companies that provides consumer’s easy access to FDA approved online prescriptions over the Internet and are quick to point out that “An online consultation can be just as relevant as an in-person consultation.” It is interesting to note that many of these online pharmacies also point out that “While they are committed to making access to online prescriptions easier, they believe that the Internet can not replace the importance of regular doctor visits to fully evaluate your health and any medical conditions.” Many of these online pharmacy sites also makes a wealth of drug information available on its web site that enables the consumer to educate themselves on drugs that may have been prescribed. The Internet has for all intensive purposes is quickly replacing the brick and mortar base physician as a patient’s primary health care provider.

A sales pitch, of course, or is it? Most of the legitimate online pharmacies ensure that they comply with state and federal regulation. The doctors are licensed in all 50 states and their pharmacies are too. These legitimate Internet pharmacies cater to those that are looking for a better price; for some it comes down to making the choice of eating cat food on crackers in order to afford their medications because of the high US drug prices. In other cases patients resort to cyber-medicine to avoid the embarrassment of having to deal with a physician or pharmacy that may be judgmental. Many of these online pharmacies will arrange a consult with a licensed, medical doctor over the phone and will then fill the prescription accordingly.

According to Henkel (2000) “More and more consumers are using the Internet for health reasons” and references a study carried out by a market research firm Cyber Dialogue Inc., “that found that “health concerns are the sixth most common reason people go online” (Henkel 2000).

For many people a trip to the pharmacy is an ordeal. In some cases the local pharmacy may also be located in the closest town which may mean a long drive if one lives in a rural community. Online pharmacies provide a means through which their prescriptions can be delivered conveniently and quickly. Being online also allows the consumer to shop for the best prices, an important factor if one is living on a pension.

The Internet has also created a more aware user. It is not unusual for a consumer to research drugs on the Internet. A consumer may have seen a TV or magazine advertisement advertising a new drug. Ultimately, the Internet also provides the consumer the opportunity to enter into a doctor patient relationship that may in fact be more legitimate than the doctor who makes a physical appearance. Further information on doctors that practice telemedicine can be found at: http://www.becomeone.com

It is interesting to note, as discussed previously, that consumers are becoming dissatisfied with the care and treatment they receive from both brick and mortar physicians and pharmacies. Zanf (2001), references a study by Lang and Fullerton that “Identified four factors related to outpatient pharmacy services: professional communication, physical and emotional comfort, demographics, and location and convenience.” All of which are contributing factors as to why more and more consumers are resorting to cyber-medicine.

The Dark Side

There is also a dark side to the Internet pharmacy, as previously discussed, spam email touting the availability of any prescription drug one could want, without a prescription, is something everyone is familiar with has reached epidemic proportions.

From Ambien, and of course Viagra to more powerful drugs such as Oxycontin, you can have it all. Over night shipping is available in most case, or so these emails proclaim.
In some instances this pharmacy spam originates from unscrupulous individuals who have no intention of delivering the drugs, realizing that very few people, if any, will complain about the non delivery of an illegal drug through the mail.

In other cases the drugs are sent without a prescription from countries where that particular drug may legally be sold without a prescription, or at least the laws are more relaxed. Valium, for example, is sold over-the-counter in Taiwan.

According to Crawford (2004) “Consumers who purchase drugs online thinking that they are they are getting the same drugs as they would from their local brick-and-mortar pharmacy are being misled, and as a result are putting their health, and eventually their lives at risk” Crawford cites examples of Internet pharmacies supplying drugs that were under strength, contaminated and mislabeled (Crawford 2004).

According to Won (2005) Drug-industry executives think the Internet and mail-order operations will be the biggest source of counterfeit drugs over the next five years, according to a report released today by Ernst & Young. According to James G Dickinson (2005):

The federal government in July shut down an alleged illegal Internet pharmacy for selling counterfeit drugs and issued a warning on other counterfeits found to have been sold in Mexican border pharmacies to individual patients from the U.S. The Internet pharmacy had sold more than $7 million in counterfeit Viagra and other prescription drugs over the past five years, according to the San Diego Union-Tribune. The San Diego-based operation required individuals to complete a $35 “doctor consultation” survey before receiving the prescriptions, but the survey was never shown to a health professional to evaluate whether a safety risk existed, the paper says (Dickson, 2005).

In a separate action, the FDA warned Americans about counterfeit versions of Merck’s cholesterol drug Zocor and generic Carisoprodol – used for treating musculoskeletal conditions – that had been imported from Mexico by individual Americans (FDA, 2005).

Over the last year patients suffering from pain, and other conditions that they are reluctant to see a doctor face-to-face, have had the option of consulting a doctor online. The ability to consult with a doctor online, and then to receive drugs as a result has come under much controversy. This has for the most part been as a result of not adequately screening patient’s records, or ordering from unregulated overseas pharmacies.

The Internet – a new way of marketing

Not all Internet pharmacies are illegitimate, however, and there are many pharmacies that provide the consumer with a legitimate prescription by overnight service. My last prescription came by mail. The whole transaction was completed over the Internet. It was a prescription that my doctor had given to me personally, however. As discussed, what constitutes a doctor patient relationship is at the crux of the online pharmacy debate. This of course has implications as to what constitutes a legitimate prescription. What constitutes a legitimate prescription is a hotly debated topic.

The Future

As noted, being able to consult a doctor over the phone, and then have one’s prescription filled by an Internet pharmacy is convenient for many people. As the American population ages, more and more people will have trouble getting to the doctors office, not to mention driving to the pharmacy. Clearly safeguards are needed if cyber-medicine is to raise the quality of medical care available to Americans. The online pharmaceutical industry has taken a number of steps to ensure that consumers are protected against unscrupulous online pharmacy operators including the certification of online pharmacies.

According to Henkel (2000) “One way consumers can ensure the quality of an online pharmacy is to look for the Verified Internet Pharmacy Practice Sites (VIPPS) seal.” According to Henkel (2000) any site bearing this seal has gone through a rigorous series of quality checks which are part of the Verified Internet Pharmacy Practice Sites program. Unfortunately as Henkel (2000) notes, “Because VIPPS certification is fairly new and voluntary, only a few sites have been certified so far.” Recognizing the problem of ‘rouge’ pharmacies, SquareTrade, has also implemented a program to protect consumers from ‘rouge’ pharmacies. According to SquareTrade, “The Licensed Pharmacy program verifies that your business is a pharmacy in good standing. Verified pharmacies can display the Licensed Pharmacy Seal on their websites – distinguishing themselves from unverified and rogue pharmacies.”

If these safe guards are not put in place, and legislation is enacted that makes it illegal to obtain a prescription from an online pharmacy based on an online consult, the black market for drugs will continue to thrive. Customs by its own admission only catches approximately 2% of all illicit prescription drugs that enter the US.

Negating the fact that through technology, one could enter into a doctor patient relationship that may be affordable. Security, as some have suggested could be accomplished through the use of video cameras and biometric scanners which would cut down on the number of fraudulent prescriptions written. Measures like these would put the convenience of using an online pharmacy out of the reach of those without the technology. One could also not prevent consumers from using off shore online pharmacies. While the FDA is presently trying very hard to get the Canadian government to enact legislation that would prohibit the export of drugs from Canada by mail it appears that the profit that results from the sale of drugs is causing the legislation to stall. As one Canadian pharmacy owner noted, however “We will just move to the UK.”

Ironically, the Canadian’s are offering to crack down, not because of any concerns relating to the sale of drugs online, but because Canada controls drug prices, making them far cheaper than the same drug in the US. The Canadian authorities are planning on cracking down “arguing that the system was created to help Canadians, not Americans.” The drug industry itself has gone so far as to black list Canadian pharmacies that sell to American customers over the Internet. With all the paranoia relating to terrorism there is a concern that any drug coming in from another country may be contaminated. There are no instances on record of a consumer having received a contaminated drug from Canada (Matthews, 2003).

Even more ironically with all the talk about the dangers of drugs purchased from overseas, some legitimate companies are now being forced to buy from other than US sources because they have been black listed by US drug manufactures (Matthews, 2003). Mathews (2003) goes on to illustrate this by pointing out that “Canadian suppliers, in particular, that have been blacklisted, are now turning to sources in Europe.” Mathews (2003) notes that while for the most part these European sources are legitimate and make a high quality drug. In some cases, however Mathews et al. (2003) note that the pharmacies are having to go ‘farther a field’ to find product.

Conclusion

While there need for controls to be put in place to regulate the practice of both medicine online and Internet pharmacies, we also need to acknowledge that science and technology has furthered the practice of medicine, and that the Internet will further it yet.

The Internet has the potential of expanding medical care to those that may not routinely seek it, or are too infirm to travel to the doctor’s office. While the present trend appears to be to make it illegal for a doctor to prescribe drugs without seeing the patient face-to-face there is also a move to establish rules and regulations that ensure that patients receive quality care over the Internet. Unfortunately medicine and politics have become so intertwined and doctors have inadvertently become unwilling agents in the war against drugs.

One can’t turn back the clock though, and according to Larkin (1999) “At a July 30 US Department of Commerce hearing on the benefits and risks of ‘drugstores on the net’, the question was examined.” The main issue was how to shutdown the online pharmacies run by unscrupulous individuals, while still fostering the legitimate online pharmacy business in order to both promote commerce and still protect the consumer (Larkin, 1999). According to Larkin (1999) “What’s new here is not the practice of pharmacy, but the way we communicate with and inform customers.”