Snapshot of Profitable Niches - About NCPA of Profitable Niches Presented by: Gary Glisson, RPh, Ward Drug Kathryn Hahn, PharmD, Manager, Bi-Mart Store Beverly Schaefer, RPh, ... of

Snapshot of Profitable Niches

Presented by:

Gary Glisson, RPh, Ward Drug Kathryn Hahn, PharmD, Manager, Bi-Mart Store Beverly Schaefer, RPh, Katterman’s Pharmacy

Terry Wingo, RPh, Madison Drugs Terry Forshee, RPh, Cherokee Pharmacy & Medical Supply

Mark Gonzalez, PharmD, INNOVRx Compounding Pharmacy Theresa Tolle, RPh,, Bay Street Pharmacy Jana Bennett, RPh, The Medicine Shoppe

7:45 a.m. - 9:15 a.m., Sunday, October 14, 2007 Anaheim, California

Evaluation # 07-128-P

This program is approved by NCPA for 0.15 CEUs (1.5 contact hours) of continuing education credit. NCPA is approved by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

Educational Objectives Snapshot of Profitable Niches: DME Theresa Tolle

1. Discuss why DME is an excellent niche for owners to consider for their business. 2. Name some obstacles to getting into the DME niche. 3. Identify critical elements needed to succeed in DME business. 4. Outline strategies to get started in the DME business. 5. Describe how to choose which niche would best fit your current or ideal business model.

2007 Kathryn Hahn Biosketch Dr. Hahn is the Pharmacy Manager and Pain Management Specialist at Bi-Mart Pharmacy in Springfield, Oregon. She is currently Chairperson of the Pain Management Commission for the State of Oregon and is Past President of the Oregon Pain Society. As an affiliate faculty member at Oregon State University College of Pharmacy, Dr. Hahn teaches a 6 week clerkship in community pharmacy pain management to 4th year Pharm.D. students. Prior to joining Bi-Mart, Dr. Hahn was a Clinical Oncology Pharmacy Specialist at Inter-Community Medical Center in Covina, CA. She earned her Pharm.D degree from the University of Southern California in Los Angeles. An active lecturer on pain management, Dr. Hahn works closely with the American Pharmacists Association on advisory boards devoted to pain care issues and has published numerous articles and APhA Special Reports, most recently ““Medication Therapy Management Services: Applying the Principles to Optimize Care of patients with Pain” (2005) and “Pharmacists’ Responsibilities in Managing Opioids: 2005 Update” (2005).

Terry Forshee Biographical Information: Mr. Forshee is a graduate of the University Of Georgia College Of Pharmacy. He is an independent pharmacist and owner of Cherokee Pharmacies in Cleveland, TN and Dalton, GA. He also owns Cherokee Medical Supply, a full-line DME and infusion company covering parts of TN and GA as well as a LTC pharmacy serving patients in those states. He is currently the President and CEO of Take Charge Nutrition, LLC a company specializing in a turnkey system to enable pharmacists to teach patients how to make positive changes in their lifestyle. Through his association with Take Charge, he has trained hundreds of pharmacists throughout the US and Canada in techniques to make a positive difference in the lives of their patients by helping them to develop Healthy Lifestyle Strategies to lose weight, control or prevent type 2 diabetes, lower cholesterol and reduce the risk of heart disease. Over the years Mr. Forshee has been instrumental in the development of many innovative ideas to advance professional pharmacy services. In 1986 he along with other pharmacists in Cleveland, TN started one of the first pharmacist owned PBM’s which eventually served more than 30% of the workforce in Cleveland. He was recently honored by the Tennessee Pharmacists Association with 2007’s Innovative Pharmacy Practice Award. He is a Certified Diabetes Educator and a trainer for the new Ten City Challenge® initiated by the APhA and TPA in Tennessee.

Terry Wingo

A graduate of Auburn University, Terry has practiced in independent community pharmacy settings since 1975. He currently owns Madison Drugs, a compounding and natural products specialty practice in Huntsville, Alabama, as well as a traditional community pharmacy in Lacey’s Spring. A member of numerous professional organizations, he also serves as president-elect of the Alabama Independent Drugstore Association. He is a Fellow of the American College of Apothecaries and the American College of Veterinary Pharmacists. In 1998 he received the Alabama Pharmacy Association’s Innovative Pharmacy Practice Award and in 2006 was honored as Small Business of the Year in the retail category by the Huntsville/Madison County Chamber of Commerce. Valuing the pharmacist’s role as educator he provides continuing education for pharmacists and nurses and speaks frequently on natural health topics.

Theresa W. Tolle Bio Theresa is President and Owner of Bay Street Pharmacy and Home Health Care in Sebastian, Florida. She graduated from the University of Florida in 1988 and worked in chain, hospital and consultant pharmacy before becoming an independent pharmacist in 1994. She has been with Bay Street since 1997 and owner since 1999. Theresa has been very active in professional organizations including serving as President of the Florida Pharmacy Association in 2003-2004. She also served as APhA-APPM Community and Ambulatory Chair in 1997-1998. She has held numerous offices and committees within APhA, FPA and is currently serving on NCPA’s Home Health Care Committee. Theresa is also a member of the UF College of Pharmacy Advisory Board and has most recently served on the planning committee for the Institute of Pharmacy Entrepreneurs. Theresa has provided presentations to professional groups on topics of Medication Errors/Continuous Quality Improvement, Value of Medicines and Legislative and Legal Updates. She also has been honored to be a featured speaker for Professional Coating Ceremonies at University of Florida and Palm Beach Atlantic University. Theresa has been honored by her peers by receiving the 2005 James H. Beal Pharmacist of the Year in the State of Florida, 2005 Distinguished Service Pharmacy Alumnus Award from the University of Florida and the 2004 APhA Good Government Pharmacist of the Year. Theresa is also active within her church in Melbourne, Florida and always finds time to spend with her husband, Joe and 3 children.

Jana Bennett, R.Ph. Owner, The Medicine Shoppe Pharmacy

Sherman, TX and Denison, TX

Jana Bennett and her husband Randy own two Medicine Shoppe® Pharmacies, which are located in Sherman, TX and Denison, Texas. Jana graduated with a Bachelor’s of Science in Pharmacy from The University of Texas at Austin in 1993. She worked for Kmart as a pharmacy manager and for a local independent – Axtell Rite Value Pharmacy prior to purchasing her first Medicine Shoppe® Pharmacy in 2003. Jana won the Medicine Shoppe Rookie of the year Award in 2004 and then purchased her second Medicine Shoppe Pharmacy in 2005. She is an active member of the Texas Pharmacy Association and The National Community Pharmacists Association (NCPA). Jana and her husband Randy are active members of their local Chamber of Commerce. They are actively engaged with prompting health and wellness in their community, conducting MTM education sessions at numerous health fairs. To further assist patients, she is a regular contributor to senior magazines explaining what MTM is and how she can assist patients with managing their medications. Jana is very engaged and active in the Medication Therapy Management arena and is very passionate about her patients and their health care needs.

1

Snapshot of Profitable Niches:Pain Management

Kathryn Hahn, Pharm.D.Bi-Mart Pharmacy, Springfield, Oregon

Affiliate Faculty, Oregon State UniversityCollege of Pharmacy

Learning ObjectivesUpon completion of this program, the participant will

be able to:

1. Discuss the importance of appropriate pain management.

2. List activities that pharmacists can engage in to improve pain management.

3. Explain how a pain management practice could be a valuable pharmaceutical care service.

4. Create strategies for implementing a pain management service into his or her current practice.

Self Assessment Questions

1. Community pharmacists represent an untapped market for pain managementprograms.

True False2. Which of the following might be stakeholders in a pharmacy-based pain

management service?a. Patients with chronic painb. Physicians who treat patients with chronic painc. Complementary and alternative medical providersd. Local employersd. All of the above

3. The pain management activities described in this niche snapshot include:a. Interviewing patients about chronic pain experiences and historyb. Educating patients about the difference between addiction and dependencec. Documenting the care provided to patientsd. Tracking patients’ functional outcomes.e. All of the above.

3

Community Pharmacy Pain Service

• Referrals to complementary and alternative therapists

• Collaborative relationship with pain practitioners

• “Pain Society” creates opportunity to market specialized practice

• 4th year pharmacy clerkship in pain management


MTM and Pain Management Services:

• Mirixa- Community Care Rx

• Outcomes- Trillium


Holistic Approach to Health

Counseling provided on:• OTC products• Dietary supplements• Complementary and alternative

treatments• Dietary habits• Physical activity levels

4


• Pain patient advocacy leads to political advocacy- State public and

regulatory pain policies

• Education of colleagues and public to improve knowledge and remove biases and barriers

Pain Service Niche Preparation

Staff training and identification of patients:

Train staff to identify chronic pain patients for special consideration:

■ Patient files■ 3 months or longer of short and long-acting

opioids or neuropathic pain meds■ Pain specialists, neurologists, oncologists,

and rheumatologists

Pain Service Niche Preparation

Identify and correct biases and weaknesses in staff education:

■ Staff education:- Decrease emphasis on regulatory imperative to not

fill bad scripts- Increase focus on therapeutic imperative to fill valid

scripts

■ Paradigm shift:- Vanquish biases and barriers

5

Pain Service Niche Preparation• Initiate consultation interviews and

profiles

• Designate one specialist technician

• Segregate part of pharmacy for pain program to contain:- pain patient files- pain technician computer and

work station

Conclusion: Program evaluation

• Designated pharmacy on contracts

• Doctors report decreased burden of care

• Patient Survey

• Profitability

Profitable Niches:Travel Immunizations

Make your pharmacy anImmunization Destination

Beverly Schaefer, RPhKatterman’s Pharmacy Seattle,WA

6

Katterman’s Pharmacy does Immunizations

• Hepatitis A, Hepatitis B, Combined A and B• Typhoid Oral and Typhoid Injectable• Yellow Fever• Polio - Meningitis• M-M-R• Tdap - Tetanus, Diphtheria, Pertussis• Shingles• Gardasil

Other travel Rx items• Antibiotics

• Malaria Prevention

• Anti-diarrheals

• Altitude sickness prevention

• Just-in-case medications

Other Travel Items

• Sunscreens• Insect repellents• Hand cleanser• Travel size toiletries• Travel pillows• Compression hose• Protective clothing

7

Travel Consultations

• CDC Website• Travax• Tropimed• Travelersvaccines.com

Profitable Business

• Most immunizations not covered by 3rd parties• People often travel in pairs or groups• Average customer-- usually new to your store• Average customer-- immunizations + $30

additional merchandise

Do the Math

• Average one travel immunization per week = 52 per year

• Average about $30 profit for each• Additional $1560 profit from immunizations

only--additional $$ from additional Rx and travel items

8

A Nutritional Approach to Chronic Diseases

A New Paradigm for Pharmacy

Pharmacist’s Focus

• Community Pharmacy is in trouble• Only pharmacists can fix pharmacy’s problems

We Must-

• Take control of our destiny• Fight for appropriate compensation for

services (NOT just reimbursement)• Break our dependence on third party payors

9

How?

• Actively support organizations that work for pharmacy causes

• Actively support elected officials who can further our causes

• Actively develop patient care profit opportunities in our practices

Therapeutic use of Nutritional Agents

• Evidence based• >20,000 medical journal articles as of 1999• Therapeutic doses differ from maintenance

doses

“People are down on what they’re not up on...” Linus Pauling

10

3 Stages of Truth

Every truth passes through three stages before it is accepted. In the first, it is ridiculed, in the

second, opposed, and in the third, regarded as self evident.

Arthur Schopenauer(19th century philosopher)

• May/June JAPhA Article:– Spitting into the wind: The Irony of Treating

Chronic Diseases

Points:

• Medications are not curative, have adverse effects

• Managing causes of chronic disease could reduce need for medication

• Pharmacists have knowledge and capacity to assist patients

11

Cultural Trend:

• Since the mid 90’s Americans have:– Had more visits to alternative practitioners than

traditional physicians– Spent more out of pocket on alternative care than

traditional care

Alternative to what?

Alternative vs. Complementary

Alternative vs. Integrative

Different tool or different approach?

The Transition: Old Paradigm

• Traditional allopathic model– Physician centered– Disease management (symptom management)– Top down

12

The Transition: New Paradigm

• Functional health– Patient centered– Disease prevention (healing)– Bottom up

Iceberg Theory

13

14

Opportunity is here.Opportunity is now.

To take advantage of it – We must prepare for it – We must claim it

Resources

• Textbook of Natural Medicine, Pizzorno and Murray

• Textbook of Functional Medicine, IFM• Textbook of Nutritional Medicine, Werbach• The Review of Natural Products, Facts and

Comparisons• Natural Medicines Comprehensive Database,

The Pharmacist’s Letter

Contact Information

Terry Wingo, PharmacistMadison Drugs

7131 University DriveHuntsville, AL 35806

[email protected]

15

Obesity: An opportunity for pharmacists to make a difference

D. Terry Forshee, PD, RPh, CDE

NEED• Adult obesity @ all-time high• >$100 billion cost to US healthcare system• 25 million children already overweight• 41 million people with pre-diabetes• 18 mill type 2 diabetics w/5 mill undiagnosed• $132 billion/yr spent as a result of diabetes• 105 million with high cholesterol• 72 million people with hypertension• Etc, ect, ect….

Source: American Heart AssociationAmerican Diabetes AssociationAmerican Pharmacists Association

Opportunity• >$35 billion spent on wt loss products and

services• Obesity rates over the last 5 years have not

dropped in a SINGLE state• Adult obesity rates exceed 20% in 47 states &

DC• US Dept of HHS set a national goal of reducing

obesity levels to 15% by 2010

Source: Trust For America’s Health – “F as in Fat: How Obesity Policies Are Failing in America”

16

Obesity Trends* Among U.S. AdultsBRFSS, 1985

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%



No Data <10% 10%–14%


(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4”person)

No Data <10% 10%–14%

17



No Data <10% 10%–14%



No Data <10% 10%–14%



No Data <10% 10%–14%

18



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19%

19



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19%

20

Obesity Trends* Among U.S. AdultsBRFSS, 1997(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. AdultsBRFSS, 1998(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%



No Data <10% 10%–14% 15%–19% ≥20%

21



No Data <10% 10%–14% 15%–19% ≥20%



No Data <10% 10%–14% 15%–19% 20%–24% ≥25%



No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

22



No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

B R F S S , 2 0 0 4 ( * B M I ≥≥2 5 %Obesity Trend s * Among U.S. AdultsBRFSS , 62005(*BMI �•30, or ~ 30 lbs. overw ei ght for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% �•30%

23



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

1998

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1998, 2006

(*BMI ≥30, or about 30 lbs. overweight for 5’4” person)

2006

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Timing• Recent study by the Institute of Medicine – “Anti-obesity

efforts remain fragmented and small-scale despite continual warnings of the consequences”

• Government & employers asking for help• Cost to US Healthcare system for obesity now estimated

at >$100 billion/year• NCPA and other pharmacy groups fighting for

recognition for pharmacists as providers

24

Why Pharmacists?• No other health professional group has stepped

to the plate to address this issue • We are highly valued by consumers for our

knowledge• Our profession is seeking an identity apart

from dispensing• Compared to the competition in wt loss

industry:– Pharmacists are highly trained– Have access to information on patient’s overall condition– Have greater knowledge of how patient’s current lifestyle choices are

affecting their health

Mechanism• How can you help a patient lose wt?• F.E.E.D. them!

– F – Food– E – Education– E – Encouragement– D – Direction

Requirements

• Private counseling area• ELG type Body Fat Analyzer• Accurate “physician type” scale• Ability to organize time• Educational materials• Record keeping system• Marketing program• Desire to change paradigm

25

Conclusion

• Resources available to help• Profit potential

– Patients will pay!– Significant addition to bottom line

• Be a solution to the problem!

Resources

• www.cdc.gov• www.healthyamericans.org• www.americanheart.org• www.diabetes.org• www.medscape.com• www.fda.gov/loseweight/• www.eatright.org• www.foodnavigator-usa.com

Veterinary CompoundingAs A Pharmacy Specialty

Mark Gonzalez, PharmDINNOVRx Pharmacy

ServicesYorba Linda, Ca

26

Why Pharmacists Explore Pharmacy Subspecialties

• To provide additional sources of revenue in the all to common 3rd party environment

• To meet untapped needs within the community• To provide a change of pace• As a challenge• To grow personally and professionally

Veterinary CompoundingWhy Is It An Ideal Subspecialty?

• It meets all of the essential criteria for a perfect subspecialty to be involved in:– Large patient population

• 63% of all households own pets– Americans own 73 million dogs and 90 million cats

– Cash paying clientele– An opportunity to build new professional

relationships– Challenging and exciting

Veterinary CompoundingHow can we help?

• Dosing Modification• Flavoring• Unique Dosage Forms• Discontinued Medications• Hard to Find Formulations• Helping the owner as well as the patient• Problem Solving!!!

27

Valuable Resources and References

-Professional Compounding Centers of America-PCCARx.com

-International Academy of Compounding Pharmacists (IACPRx.com)

-International Journal of Pharmaceutical Compounding (IJPC.com)

-Plumbs Veterinary Handbook

Snapshot of Profitable Niches: DME

Theresa Tolle, RPh

Why DME/Home Health?

• Population aging• Many patients leave hospital with rx for

equipment• Natural extension of care for pharmacy• Opportunity for additional revenue

28

Why NOT DME/Home Health?

• Concerns about competitive bidding/accreditation

• Ongoing cuts in reimbursement by Medicare/other payers

• Not enough knowledge• Start up costs• Billing/payment concerns

Elements needed to succeed

• Study your market• Have a plan• Talk with colleagues who are in the

business• Understand billing requirements• MARKET!!

Strategies to get started

• SWOT analysis• Talk to physicians and patients• Look at profit margins• Obtain additional education if needed• Just Do It!

29

Medication Therapy ManagementJana Bennett, R.Ph.

Medicine Shoppe PharmacySherman, TX and Denison, TX

What is Medication Therapy Management (MTM)

• MTM Definition– Programs of drug therapy management whose goal

is to ensure that medications provided to patients are appropriately used to:

• Optimize therapeutic outcomes through improved mediation use

• Reduced the risk of adverse events

Why MTM?

• Mandated by Medicare Part D• Centers for Medicare and Medicaid Services (CMS)

commitment• Movement to commercial sector• Call centers, nurses and non-retail pharmacists as

potential competitors• Revenue• Niche opportunity• Future of retail pharmacy

30

MTM Opportunities

• Medicare Part D – Web Based: Ex. Mirixa Corporation– NCPDP Version 5.1: Ex. Humana

• State Medicaids• Commercial Sector

Pharmacy Training & Workflow

• Train all pharmacists and technicians on MTM opportunities available

• Define a process for MTM completion• Reward pharmacists and technicians for a job

well done• Delegate, Delegate, Delegate

Delegation

• Appoint a technician (s) to complete the following:– Check available cases each day/week– Schedule appointments– Gather necessary information – Ex. Allergies,

conditions and medications– Billing

31

Support

• Identify Groups/Associations as Information Resources– National Community Pharmacists Association

(NCPA), American Pharmacists Association (APhA), National Association of Chain Drug Stores (NACDS), etc.

– Franchisor– Affiliations (examples: Cardinal Health – Leader

and United Drug)

Support (Cont’d)

• Forms of Communication– Blast Faxes– Webinar/Online training– Intranet Communication– Newsletters– Call Campaigns

Call To Action!!

• Individual store initiative• Peer driven initiative• Complete your cases!

32

Experience: Sherman TXMedicine Shoppe Pharmacy

• Minimal upfront costs• Documentation of service provided• Rewarding to patients• Niche opportunity• Marketing opportunity• New revenue stream

Take Advantage Now!

• MTM should be completed by retail pharmacists

• Don’t let call centers and nurse practitioners take this opportunity

• This is the future of retail pharmacy– Move from dispensing fee model to professional

service fee model with dispensing

Medication Therapy ManagementJana Bennett, R.Ph.

Medicine Shoppe PharmacySherman, TX and Denison, TX

Learning Assessment Questions Snapshot of Profitable Niches: DME Theresa Tolle

1. True/False The DME niche can be very profitable and should be a consideration for owners looking to expand their business model.

2. True/False Obstacles to venturing into a DME niche could include concerns about accreditation, competitive bidding, billing for Medicare Part B, and start up costs.

3. Which of the following are elements needed to succeed in the DME business: a. Performing a market analysis/needs assessment b. Understanding payer requirements (Medicare requirement for accreditation) c. Having a good marketing plan d. All of the above e. None of the above

4. True/False For providers who will be billing Medicare Part B, only those who are in a competitive bid area need to be concerned about becoming accredited.

5. True/False A “SWOT” analysis is a good way to evaluate what niche might work best in a particular location.

Learning Assessment Answers Snapshot of Profitable Niches: DME Theresa Tolle Answers:

1. true 2. true 3. d 4. false 5. true

Documents

Snapshot of Profitable Niches - About NCPA of Profitable Niches Presented by: Gary Glisson, RPh, Ward Drug Kathryn Hahn, PharmD, Manager, Bi-Mart Store Beverly Schaefer, RPh, ... of