COMMUNITY CARE AT CHAINS CALLED ACHIEVABLE CHALLENGE

MICHAEL SLEZAK

GARDEN CITY, N.Y. -- Community-oriented pharmaceutical care can take place at the chain level despite a bevy of obstacles, according to a CVS pharmacist who spoke here last month.

"I practice community pharmacy," said David Setta, manager of a CVS pharmacy in Binghamton, N.Y., speaking at the 36th Annual Pharmacy Congress, sponsored by St. John's University College of Pharmacy, Jamaica, N.Y. "You'll hear me refer to 'my store.' Even though I work for CVS, I have a sense of ownership and a sense of pride in the store." CVS, headquartered in Woonsocket, R.I., operates 1,087 pharmacies.

At the same time, Setta said, it's getting harder for pharmacists to give the pharmaceutical care that patients need. "I've been a CVS pharmacist for 15 years. As margins shrink, the pressure on chain pharmacists is to fill more prescriptions with less help. This affects my ability to give pharmaceutical care."

He pointed to third-party plans, now 65% of his business, as the direct cause of those shrinking margins.

Despite these problems, Setta said his store has increased its prescription volume. "I attribute the increased number of prescriptions to a few factors. Two years ago we started staying open 24 hours, and that's increased business. Even if people are never going to come in in the middle of the night, they like knowing they can."

Setta said the second reason his store's prescription volume has increased is the personal care he gives and the customer loyalty it creates. "People come in because Dave Setta is the pharmacist there," he said.

The people coming into his store, however, are better informed about pharmacy than ever before, Setta said.

"People that we counsel may have books at home listing the side effects of medications. You need to say to them, 'Before you make a decision to stop the medication, call your doctor or call me, and let's talk.' "

Setta said OBRA '90, too, "gave a lot of our colleagues a kick in the behind. It got them out from behind the computers, out there talking to more patients.

"I just wish I could convince the third-party payers that catching an interaction with penicillin, for example, saves the customer an uncomfortable rash or even their lives," he said.

The public is becoming aware of the pharmacist's requirement to counsel. Setta said that when he attended a meeting of the American Association of Retired Persons as a speaker, AARP handed out a sheet that read: "'There is a new law that requires all pharmacists to talk and answer questions about medications.' Here's AARP, which supports mail order, so I thought it was kind of neat. The sheet said, 'Choose one [pharmacist] and get to know and trust each other.' "

Mail order, said Setta, is another factor hindering community pharmacy care. "Mail order's distribution system is marvelous. It's their pharmaceutical care system that doesn't work," he said.

Another health care phenomenon that doesn't work, said Setta, is managed care. "There is no such thing as managed care," he said. "I care for my patients. Insurance companies manage cost. But they can't come out and call it a managed cost system."

Setta said there are times when he challenges insurance companies, although the process is time-consuming and costly. One woman who had her purse stolen lost her blood pressure medication. But when Setta tried to refill it, the message "refill too soon" came up.

"I asked to speak to a supervisor and said, 'Are you managing care or are you managing cost? If you're managing care, then refill the prescription, because that's 20 days she'll go without her blood pressure medication,' " Setta said, adding, " 'I'd like to document who this is in case you make the decision not to pay for the medication and something happens to the patient.' They approved the claim."

Challenges that lie ahead for pharmacy, said Setta, include getting paid for cognitive services, surviving competitive pressures and dealing with the aftermath of health care reform.

"With health care reform, we'll have 1 billion new prescriptions, or a 50% increase. What will this mean for pharmaceutical care? "Are we going to move back a step to just distribution because we're so swamped and our reimbursement rates are so low? Will there be an extra pharmacist so we can provide pharmaceutical care? When we fill a prescription, we have to think about what our action or our inaction will do to each patient."