Following the receipt of allegations made by a “whistleblower” and a July inspection the HSE was written to Irelands largest Pharmacy retailer with fraud and breach of contract allegations. The story broke yesterday and has already had wide coverage in Irish media that will be very damaging for the brand as no journalists seem to have the first idea about what’s really at stake here:
As proponents of innovative uses of mobile technology to help improve the quality of Patients and Carers lives I naturally champion innovations like the MyMeds service being brought to market by Healthcare Professionals (and the major retailers they work for who have the resources to invest in this opportunity) as they are very well placed to support the education of Patients and Carers and spend time helping them make the best use of their mobile phones and mobile connected medical devices.
To be very clear we have provided consulting services to Lloyds Pharmacy’s parent company, presented at their annual staff conference and we regularly share the MyMeds service (that is at the centre of these allegations) in talks that we give to Pharmacists as an example of best practice.
Dispensing fees are a very blunt measure of the value that Pharmacists provide and the HSE focus should not just be about decreasing them
Trying to measure the value of Pharmacists by comparing their dispensing fees is daft and outdated. Here’s an experience that I think illustrates this well:
A few years ago I was talking with an Irish Pharmacist about the issue of Patients who don’t take their medications and she shared with me a story about a carer that called into her Pharmacy retail store. An elderly relative had recently passed away and while clearing her home the Carer had noticed loads of medications that had not been opened/taken and they wanted to know what to do with all the medications because they were concerned about the potential harm they might cause if put in with the household refuse. The Pharmacist asked them to bring them in as they’d be grateful to dispose of them safely. Two days later the lady walks in and hands over the counter 3 carrier bags full of unopened and unexpired boxes of medications. I asked the Pharmacist what the value of these medications might’ve been and was told it was in excess of €1,500 to the Irish Taxpayer for the medications alone plus the wasted Doctor appointment and prescribing costs plus of course the Pharmacy dispensing costs.
In the UK a few weeks later I shared this story with a group of NHS Pharmacists and was told that they get exactly the same thing happening. Stunned I asked about how much this Pharmacist felt was being wasted because of the distancing the healthcare service has once the medication is dispensed and the Pharmacist started doing back of the envelope calculations for me. It then dawned on me that the problem in the UK’s NHS is much bigger – the Carer that visited his store wasn’t holding 3 carrier bags they were holding 3 full black refuse sacks!
The HSE needs to start rewarding Pharmacists for work they do above and beyond dispensing
For a more in-depth understanding of this area check out this recording of a “Beyond the Pill” webinar that I participated in with Pfizer’s Global Head of Solution and Product Development and Mark Wilkinson (CEO of NHS Barnsley’s Clinical Commissioning Group) back in 2013.
The MyMeds service is a great example of Pharmacists working to support Patients taking medications. It’s probably not going to be for everyone but it has huge appeal amongst those for whom medication regimes are particularly difficult and where adherence is very low and challenging.
Politicians and Healthcare Ministers claim that they want to drive efforts to improve medication adherence but what signal does it give to the market if the brand that has invested more than €200,000 building a new service gets accused of fraud and breach of contract just because they highlight how out of date HSE reimbursement strategies are?
It’s not wrong to make money from helping the HSE get value for money from the drugs they prescribe
There should be no misunderstanding: the most expensive drugs in Ireland are those that Doctors prescribe, Pharmacists dispense and Patients don’t take.
When a business like Lloyds Pharmacy works out ways to make some money by increasing Patient adherence it’s important to appreciate that they’ll be more than making up for the extra revenue they’re taking from the HSE with the extra savings that the HSE will be getting from the better care that the Patients are receiving.
Patients who are more compliant with their Doctor prescribed medications maintain their good health for longer, can remain working for longer, make fewer demands on their Carers and have much lower long term care costs because they avoid expensive avoidable Hospital admissions and Hospital stays.
It’s the role of the HSE to set robust rules not to flame anyone who follows them.
What I’d like to see happen?
I think Lloyds Pharmacy should seek an immediate retraction of these damaging allegations and the HSE accountants who made them and any directors/investigators who were involved should be required to receive training (eg. the course that we developed for the Healthcare Informatics Society) as the adoption of mHealth is being held back by ignorance that flies in the face of calls by highly respected organisations like the International Diabetes Federation for mHealth to be embedded as a compulsory part of how we provide quality care for Patients with chronic conditions.
What would you like to see the HSE and Lloyds Pharmacy do next?
*** UPDATE Sat 29 Aug 8pm ***
A Doctor I have incredible respect for and who is much smarter and more experienced than I has emailed me on reading this post and suggested that while “controlled dispensing is going to save the NHS millions and is so logical” I shouldn’t be so direct in my support for Lloyds Pharmacy in this instance because they have “focused so much on profit in their encouragement tactics” and may have “bent the rules over claiming because for instance they may be giving Patients a months supply at a time and claiming for each week separately which doesn’t not stop the waste if they don’t take them!“.
I think this comment highlights the fact that we’re in very new ground here and it’s critically important that healthcare payers (the HSE in this instance) not only appreciate that there is an enormous pharma mHealth opportunity (Walgreens have the #1 revenue generating healthcare app generating more than $320 million per month) but that this is something they can positively influence via the terms that they stipulate.
Smart healthcare professionals (in this instance Pharmacists) face immense economic pressures and it’s critical that they’re financially motivated to do the right thing by Payers who are smart and act in the best interests of Patients. While it would be ideal if we had ways to pay Pharmacists for the medications Patients swallowed this isn’t realistically achievable today but that doesn’t mean we shouldn’t take steps towards this goal.
I think the MyMeds service is an important stepping stone forwards because we all know how big an issue poor medication adherence is (>50% of Patients aren’t adherent to their prescribed medications), no one else is making an impact on this and here we have private sector Healthcare Professionals not only doing this but finding an economically viable means (so that it is financially sustainable) of creating an app, marketing it directly to Patients/Carers, helping with the tech issues, etc, etc, so that Patients have reminders (from the device they already carry with them all the time) and are recording their adherence to individually packaged pills.
The MyMeds service has moved the goal posts. Payers shouldn’t be hunting innovators but should focus their efforts on working out ways of penalising all the other Pharmacists who don’t have enough interests (or perhaps don’t care enough?) to offer med reminder/adherence services that (the traction of MyMeds shows) Patients and Carers clearly want.
*** UPDATE Sun 30 Aug 7pm ***
In this RTE Radio 1 interview Darragh O’Loughlin, Pharmacist and CEO of the Irish Pharmacy Union (IPU.ie) while stating clearly that he can’t speak for any actions Lloyds Pharmacy may have taken (as they aren’t an IPU member) or these specific HSE allegations has made some great points when asked in what circumstances it is appropriate for Pharmacists to dispense medications in this phased way and be reimbursed by the HSE for doing this:
“There a number of circumstances or situations in which it is absolutely appropriate for a Pharmacist to dispense a Patients medication in these phased weekly doses, for example it could be a case that the Patient has an addiction problem or abuse problems with medication dependency issues so it’s appropriate that they would only be given small quantities at a time. There can be occasions when there is a risk of diversion of medication for example anxiety or sleeping pills that might be legitimately prescribed for one Patient but are being diverted then into the illegitimate market and in order to prevent that Doctors or Pharmacists might decide only to give them out in small quantities. But the major issue is with the increasing complexity of medication regimes and the increasing number of elderly Patients and the people just simply get a bit confused about their medication or they’re not taking their medications properly as prescribed – they could be missing doses or doubling up on doses and this can come to the attention of the Pharmacist or the Patients Carer and in order to prevent that from happening the Pharmacist will often say we will dispense that medication in these weekly trays done out by day – intact by morning, mid day, afternoon and evening dose so that it’s easy to see that the Patient has taken each dose at the appropriate time… …it’s a facility that’s there for Pharmacists to provide a service to assist Patients in taking their own medication appropriately or to prevent abuse or misuse of medication, or simply because medication has a short shelf life such as with children’s antibiotics that last for a week so fi a child needs to take it for a number of weeks they have to return each week for a fresh course… …the HSE has all of the dispensing and fee information on every Pharmacy in the country and as a taxpayer I would expect them to engage in an ongoing audit of that just to ensure that money is being expended appropriately but your question was would it ever be appropriate to dispense a months medication in one go and then to claim for having dispensed it weekly – if I understand your question? – and in that case where the Pharmacist is doing out weekly trays which set out dosing on a daily basis to our Patients it’s almost a bit of a red herring as whether four trays are handed over to the Carer at the same time or they are handed over every fortnight or every week because what is being put in place is the facility to monitor Patients taking their medications on a daily and weekly basis to ensure that they’re taking it properly. So Pharmacists will frequently give those trays out on a weekly basis to a Patient who comes in so that they can have that weekly contact and see that this individual is still taking their medication but there could in other circumstances be a Carer who says I want to take responsibility for these trays and I’m going to give them over to my mum or my dad – or whoever it might be – on a weekly basis but I don’t want to visit the Pharmacy every week because I don’t have time and in that case it’s reasonable for the Pharmacist to give the four trays over and say this is week 1, week 2, week 3, week 4 and this is how it works…”
*** UPDATE Mon 31 Aug 11.40am ***
Interesting to note that today the HSE is promoting Overdose Awareness Day:
The awareness video the HSE has produced is also very revealing:
“(5min45sec Daniel) …my experience with overdose would be I was in prison for 9 months and the very day I got out I went to my Doctor and without seeing him he gave me fifty Xanaxs (Alprazolam – a Benzodiazepine medication). I took six of them and couldn’t remember anything after that (but) I took heroine on top of that and I was took back to the hospital…”
The Health Research Board has claimed that in 2012 there were twice as many killed from overdoses than killed in road traffic accidents and that there has been a “considerable” increase in the number of deaths involving prescription medication eg. in more than half of the overdose deaths last year there was more than one drug used and after alcohol the most commonly found other drugs used were diazepam, methadone and anti-depressant medications.
*** UPDATE Tuesday 1 September 11am ***
A reader contacted me with the suggestion that it’s not clear what the “MyMed” service entails. Here’s a link to more info on the exclusive tablet pack into which Lloyds Pharmacy dispense medications:
For more detailed information check out this PDF of the leaflet that is being distributed in retail stores for Patients and Carers to consider:
*** UPDATE Monday 7 September 11am ***
This news story from California about a GP being charged with 2nd degree murder for prescribing prescription drugs to Patients who later died from overdosing reminded me of the value that phased dispensing by Pharmacists can provide for Patients/Carers when there are abuse problems of the type that Doctors aren’t always well placed to monitor.
Tweeting my thoughts led to the following interaction with Matt (@DocMait) that I think highlights a lot of anti business concepts that I see preventing a lot of clinically validated Healthcare innovations from getting adoption:
We need to ensure in our training of healthcare professionals that they appreciate it’s desirable to align making money as a healthcare professional with providing the modern services that Carers and Patients deserve.