In Part One of this series (available online at PracticalDermatology.com), I discussed the growing problem of brand name and expensive generic medications becoming more difficult for our patients to obtain. Our most important tool, discount drug coupons, was also discussed in detail. Now we move on to additional techniques to make prescribing these drugs more successful. The goal is to help our patients get their prescriptions filled or obtain an acceptable substitute on their first trip to the pharmacy. This higher level of prescribing expertise increases patient satisfaction by providing a more trouble free experience obtaining their medications. It can also increase adherence because if patients can't get their medication they can't use it. As a provider you will be able to prescribe with confidence knowing you are doing everything possible for your prescription to be successfully filled. In addition, your staff will benefit from decreased pharmacy and patient callbacks regarding medications and will have the skills and knowledge to handle the callbacks you do get more effectively. Expanding Our Role and Updating Our

EXPANDING OUR ROLE AND UPDATING OUR SKILLS TO SUCCEED IN A CHALLENGING PRESCRIBING ENVIRONMENT

As you read about the three techniques in this article—“Staff Training and Patient Education,” “The Backup Prescription,” and “Referring Patients to Your Pharmacy”—you may notice an underlying expansion of the provider's role from the traditional “diagnose and treat” function to include one more, similar to an engineer and guide, setting up systems both within and outside your office to obtain better prescribing outcomes and educating patients on the tools you are using to help them. Busy as we are, the last thing we want to do is add any new activities to the patient encounter. But let's look at this in a familiar way, through a cost/benefit analysis. The cost side is the increasing problems caused by “bad prescribing outcomes,” which is real, disruptive, costly, and increasing (explained in more detail ahead). Also on the cost side is the education, training, and extra time with patients it takes to reduce poor prescribing outcomes. Once you absorb the information in this series and train your staff to become fluent using these techniques, you will see that incorporating this new knowledge is clearly a huge advantage for your practice and well worth your time. For the provider it only takes an extra 30 seconds in the treatment room. It is certainly less work than picking up the pieces after a prescription can't be filled, which is what is increasingly happening as prescription drug coverage becomes more restrictive.

REDUCING “BAD PRESCRIBING OUTCOMES”

We are bound to have a patient stuck at the pharmacy unable to get their medication because it is too expensive, not covered, or needs prior authorization. If you haven't prepared the patient for this and set up a contingency plan, you can have a “bad outcome.” The patient may be upset or at least frustrated. The patient may view you as less of an expert for prescribing an expensive medication that wasn't covered. Worst of all, if these issues aren't resolved in a timely manner, the patient may not get his/ her medication at all. If the patient is for some reason dissatisfied with his/her office visit, problems at the pharmacy could be the catalyst for becoming an ex-patient or possibly complaining to the referring physician. In some cases it can lead to poor compliance. For example, when you prescribe one oral acne medication and two topical medications, if one of these medications isn't covered, the patient will simply not get it rather than go through the hassle of trying to get the prescription problem resolved. S/he may or may not tell you on follow-up that s/he is only using two of the three medications.

The following techniques are aimed at reducing these bad outcomes. They are not extremely time consuming to explain or difficult for patients to understand. Combined with drug discount coupons, these techniques dramatically improve your prescribing effectiveness. Patients appreciate that you have the expertise and are making an effort to get them the best medication while saving them time and money. It sends a clear signal that you are going the extra mile for them, which helps build a strong patient-provider relationship.

THE FOUNDATION: STAFF TRAINING AND PATIENT EDUCATION

To ensure pharmacy problems will be resolved quickly, providers have to take the lead and train a designated staff member. Have this staff member read these articles and explain why you are enacting these changes. Next, go through the brand name or expensive generic medications you prescribe one by one. Write down the proper substitution for each medication (of course, staff always need to clear the prescription change with you). Because coupons are so important, make it the staff member's responsibility to work with the pharmaceutical representatives to keep them in stock and understand how the coupons work. Specify any medications you do not want to do a prior authorization for and for which you would like another medication substituted instead. Last, make sure your staff understands that patients experiencing problems getting their prescription should have prompt assistance and need priority status. Now you can confidently say to patients, “if you are having any problems at the pharmacy and cannot get these medications at a reasonable price, don't hesitate to call our office so we can get the problem resolved as soon as possible.”

THE BACKUP PRESCRIPTION

A backup prescription is simply one that includes the brand name medication and the substitution, with clear instruction under what circumstances the substitutions can be made on the same prescription (this can be done with paper or e-prescriptions). It is a great technique, because it gives the pharmacist all the information he or she needs to fill the prescription right then and there. Pharmacists have no problem with this practice as long as you are specific in your instructions. In most cases I write the following below the brand name drug: Please substitute “generic medication name” and sig [if sig is the same you can write “same sig, size, and refills”] ONLY if brand name medication is too expensive for the patient, needs prior authorization, or is not covered. The “needs prior authorization” portion can be left out if you wish to do the prior authorization, should the need arise. Explain this in one or two sentences to patients so they won't be surprised if their medication gets changed. Patients easily understand the backup prescription concept. Make sure you present both medications in a positive light, one being the best and the other being very good. This way the patient will be happy with either.

The first time you write a backup prescription to a pharmacy, it is a good idea to call them so they understand what you are doing and that you want all efforts made to fill the brand name before the backup medication is filled. If the medication is changed, the pharmacist should send you a fax detailing the change for your records. Stamps for paper prescriptions and cut and pasting from a word document into the e-prescription can be used to save time creating backup prescriptions.

REFERRING PATIENTS TO “YOUR PHARMACY”

I once practiced in a satellite office in a small town that had only two pharmacies. The independent pharmacy was right across the street. I got to know the pharmacist well. He kept the drugs I prescribed and the over-the-counter products I recommended in stock. He was also great at processing coupons, understood my prescribing preferences, and treated my patients like VIPs. He even communicated with me by text to resolve problems faster. The relationship worked great. Because it was right across the street and half my patients were already customers, it was easy for me to refer patients there. I would just let them know that the pharmacy had the prescriptions or OTCs in stock. Back at the main office, I prescribed to dozens of pharmacies and had more problems: patients had to wait because drugs weren't in stock. They may not have the OTC skin care products I recommended in stock, either, and there seemed to be more problems processing coupons.

Patient feedback indicated lower satisfaction than my patients at the satellite office enjoyed from the independent pharmacy. To get my patients the superior pharmacy experience they had in my satellite office, I decided to form a relationship with an independent pharmacy nearby.

The first step is to find an independent pharmacy (chain pharmacy's will not be receptive) that is willing to do most of the following things: keep certain brand name medications that you frequently write in stock, do everything possible to process all coupons, price match for your cash patients, and, if you recommend a lot of OTC skin care products, keep those in stock, too. If the pharmacy has compounding capability, even better. Within walking distance or in your medical building is ideal. Depending on their business model, some pharmacies may be interested in working with you and some not. There is likely a pharmacy in your region or state that specializes in dermatology, will do most of the tasks described above, and will deliver by mail, usually at no additional cost. Asking drug reps or your colleagues is the best way to find these pharmacies.

When contacting the pharmacy, have available a list of medications you prescribe most frequently, the coupons you use, and any skin care products you commonly recommend. Include in that list the substitutions you want made and which medications you want to do prior authorizations for. If there are medications you typically prescribe for cash patients, like acne medications, many independent pharmacists will offer some type of price matching with chain pharmacies. If you prefer the pharmacist to call your office or cell phone or text you, discuss that as well. Now that you have a working “contract” with the pharmacy you can start referring patients there. I tend to refer patients to my pharmacy for brand name or expensive generics, cash medications (when I'm sure they are the best price in town), and especially with coupons and backup prescriptions.

When presenting this option, the key is to present your pharmacy as a helpful option to patients, never being pushy. Referring patients to another specialist, like a rheumatologist, is a behavior patients expect from us. They most likely do not have a rheumatologist and need a referral. Referring to a pharmacy is a different matter. Patients already have a pharmacy, so you have to explain the advantage of using your pharmacy and offer it as an option rather than a direct referral. You can say something like this, “These are excellent medicines but sometimes getting them covered is difficult, even with this coupon, and they may take a few days to order. If you run into any trouble at your pharmacy call this pharmacy (hand them a business card). They specialize in dermatology and have these medications in stock.” This takes 15 seconds.

The patient then typically responds in one of three ways: They say “thank you” and take the card. They seem indecisive but interested; In this case emphasize that they can always have the medication transferred. Many patients express a strong interest and request that I send it in to my pharmacy.

Patients are very comfortable when I present it in this way. I often get thanked on follow-up visits for the good experience they had or the money they saved because my pharmacy had more success processing the coupons. When you start sending many patients to one pharmacy, and the pharmacist knows you personally, your patients become VIPs and not just another person at the counter.

PRESCRIBE WITH CONFIDENCE

All forecasts predict that brand name and expensive generics will become increasingly difficult for our patients to obtain. As this happens we may find ourselves hesitant to prescribe the medications we think would benefit the patient most because we fear that the prescription may not be covered, leaving patients upset and delaying treatment. With the information in this series you can now approach the prescribing of these medications with more confidence by educating patients and forming effective contingency plans. Since I enacted these changes in my practice, patients are much happier and rarely present at follow up complaining that they weren't able to get their medication. My staff is happier, too, as they have fewer pharmacy callbacks and have more tools and training to resolve prescription problems. As a provider, I am happy knowing that by becoming a better prescriber I am ensuring improved outcomes, adherence, and a better patient experience.

Steven Leon, MS, PA-C is on staff at LA Laser and Skin Center in Palmdale, CA.

Pete Farzadfar, PharmD is the owner of Lyons Pharmacy & Compounding Lab in Valencia, CA. He has a special interest in dermatology drugs and compounding and can be reached at (661) 777- 7770.