Thoughts on ordering, stocking, dispensing thousand-dollar pills
Monday, February 02, 2015
Question: How do you hold a $28,000 bottle of pills?
Answer: Very carefully.
A lot of talk has been going around about how health plans are figuring out which HCV treatment they will place on their preferred formulary. AbbVie and Gilead have been throwing punches, trying to muscle their way into more market share.
But not a lot has been said about what ordering and stocking a drug like Harvoni involves from the pharmacy side. For pharmacies who serve health plans with open networks, determining how (or if) to pursue this line of business is a big decision.
I still remember the first time I ordered and received a bottle of Harvoni, the latest treatment for HCV by Gilead. For those who work in a specialty pharmacy, you probably have become immune to the sensation.
But for the rest of us, particularly if you are sensitive to budgets and invoices and reimbursement issues, holding $28,000 in pills in one hand is a strange experience. Now that I have dispensed it many times, the magic has worn off a bit. But I'll always remember that first time.
Think about what $28,000 buys you today. The sticker price on a brand new 2015 Toyota Camry LE is just $24,000. Throw in tax, registration and heated seats, and you are right up around that $28K price.
I priced out some all-inclusive vacation packages to Hawaii, and a cool $28,000 would get you some very nice accommodations — for a month! That bottle of Harvoni could also get you three tickets to the Super Bowl.
Maybe millionaires think nothing of holding a $28,000 product in their hand, but I find the whole thing rather sobering.
Then think about the invoice. For huge companies with deep pockets and virtually unlimited cash flow, seeing a $28,000 line on an invoice may mean nothing.
However, if you are managing a smaller pharmacy on a tight budget with limited credit, getting involved in dispensing these drugs takes some courage. You may not see your reimbursement for 60 to 90 days. During that time period your patient will have returned at least once, maybe twice, in order to complete their 8-12 week course of therapy.
Then think about storage issues. Assuming you are starting to generate a regular stream of such business, you may need to keep a bottle or two on hand for the providers who want their patients to start this therapy as soon as they get the insurance authorization.
Do you stick it on the shelf alphabetically, nestled in between a $3 bottle of glipizide on the left and a $4.50 bottle of isosorbide on the right? Personally, I'm in favor of locking it in the safe and treating it like a controlled substance.
Then think about delivery to the patients. In all likelihood they will be actually paying little to nothing for these tablets themselves. Now you not only have to counsel them on the medical aspects of this drug, but also on the financial aspects as well.
For example, don't drop one down the sink. Don't lose this bottle on the way home. Don't let it sit on your car dashboard on a scorching hot summer day for hours while you do your shopping.
If you ship it to the home, be prepared to insure your package for the full value of what you are sending. If you are hand-delivering it to a patient's home or physician office, I suggest you create a form with a signature line to document who received it.
Finally — and maybe most importantly — think about the margins. When just starting out, would you dare order this drug until you are sure you can actually make a profit on it?
I have read some horror stories from independent pharmacy owners who commit to supplying this drug to a patient, get the authorization to do so, only to discover they are going to lose hundreds of dollars on each fill.
I even read one story about a pharmacy that was asked to dispense just 14 tablets (half the bottle) just to ensure the patient could tolerate the medication before getting the other 14. That half bottle could sit on the shelf and expire, costing the owner thousands of dollars. I would never recommend agreeing to that.
Dispensing specialty medications offers great opportunities to serve a new patient population that needs our help. Doing so in a way that is both responsible and profitable is essential — not only for the health of the patient, but for the health of your business.
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