Going Postal Over Mail-Order?

You don't have to. Here's how to deal with the new breed of pharmacies.

Are your office phones ringing off the hook? Is your fax machine spitting out more paper than ever before? Is your staff seeing the word "prescription" everywhere it turns? Maybe your practice hasn't been hit yet, but there is one thing you can depend on: Mail-order pharmacies are here to stay - and probably will service more of your patients in the future.

"Pharmaceuticals in general are becoming out of the reach of the average person, and the average person is getting older," says Rebecca Anwar, president of The Sage Group, a practice management consulting firm with offices in four states.

More than half of all Americans regularly take at least one prescription medication, according to a report by the American Society of Health-System Pharmacists. Over three-quarters of seniors take at least three medications, and about one-third take more than eight.

"When you start paying for all these copays, it just is becoming really hard," says Anwar.

With prescription costs growing at about 15 percent a year since 1999, mail-order pharmacies that promise up to a 25 percent savings for members - once all benefits, like using generic drugs in place of brand names and large rebates from pharmaceutical manufacturers for bulk purchases, are figured - seem increasingly attractive to both employers and insurers looking to cut costs. Most insurance plans now offer a mail-order option, and many are actively pushing members toward it.

Does that leave your practice stuck in the middle?

A new kind of problem

"When you deal with a pharmacy that is local, you just write the script, give it to the patient, they take it to the pharmacy, and that's it," says Anwar. The process can be very different with mail-order pharmacies, however. "There are other kinds of paperwork, such as sending [patient insurance] numbers or reconfirming why it's necessary - or more documentation for why the script is being written."

That kind of paperwork may not be a problem for a practice with only a handful of mail-order patients; indeed, many practices have yet to face any challenges.

That may be because mail-order pharmaceuticals are still a relatively new phenomenon - a fact that's changing fast.

"It's yet another practice management issue that is emerging, rather than something that is commonplace that we know how to deal with. It's emerging - and taking more time," says Anwar.

Some practices are already overwhelmed.

"For the ones that do get involved in it, it's just an incredible amount of paperwork," says Gail Lorenzen, a consultant with The Sage Group.

Returning paperwork quickly can present problems for employees who already feel pressed for time. But that may be only the beginning. With different patients come different insurance plans - and that means a wide array of formularies and coverage.

As more health plans push their members toward the mail-order option, practices could soon find themselves dealing with more paperwork. Every indication points to the trend continuing.

"It's going to keep getting larger and larger," says Lon Castle, MD, director of medical affairs for Medco Health Solutions, the largest mail-order pharmacy in the U.S. Medco filled 88 million prescriptions by mail last year - 10 million more than the year before.

"Particularly as healthcare and drug costs go up, our clients - basically healthcare plan companies - are going to be looking at ways to divide up a finite amount of money," adds Castle.

Strategies and challenges

So far, no consensus has emerged on a strategy to deal with these new demands on staff time. Practices have been handling both phone and fax queries from mail-orders on an ad hoc basis.

Some physicians are taking a hard-line approach to the problem, charging a fee for mail-order forms - just as they do for filling out summer camp forms or other "extra" paperwork - hoping the surcharge can help make up for the demand on staff.

Others have gone so far as to refuse to complete mail-order paperwork. Instead, they ask patients to complete the forms themselves and bring them for the physician to sign. Lorenzen sees a number of problems with this approach. For one thing, it opens the process to patient error. Moreover, it could result in patients never filling out their paperwork - and never filling prescriptions they need.

Most practice management consultants recommend batching mail-order requests.

"What they need to do is deal with it at a particular [time], from 4 p.m. to 5 p.m. ... or whatever. Or have a special person who deals with pharmaceutical requests, if they can," says Anwar. "But, again, it's one more thing to batch. Also, some of it's electronic, some of it's fax, some of it's telephone calls, so [practices] still need to figure out a system for dealing with it."

But Lorenzen warns that batching may not always be feasible, especially when a patient needs a prescription right away. "You can't not get people their medication. It sounds very reasonable and logical, but sometimes that doesn't always work."

Where do you go from here?

Because mail-order pharmacies are dedicated to finding cost savings wherever possible, practices are more likely to experience an increase in calls about substituting lower-tiered, generic prescriptions.

For its part, Medco is already looking at solutions. "We've done a lot of focus groups with physicians and are looking into a way of batching calls and sending things at convenient times for [physicians] so that it can fit into their workflow better. We are in the process right now of redesigning our systems to make that a reality."

In the meantime, though, Castle has a few suggestions to help practices help themselves:

• Write clearly. Illegible handwriting is a persistent problem for traditional pharmacies, and states like Florida and Washington have already enacted legislation to enforce legible prescriptions. Now mail-order pharmacies are starting to encounter problems: Almost 9 percent of new prescriptions at Medco require a call to clarify the prescription, and nearly half of those calls are because the drug name, dosage, or directions are illegible. If you write clearly, you can save yourself a follow-up phone call.

• Prescribe generic medications. Castle recommends prescribing generic drugs whenever they're appropriate and available. Mail-order pharmacies cut costs by using generics in place of brand-name pharmaceuticals. Generics are usually first-tier drugs in most formularies: low-cost and approved for all patients. If a physician doesn't prescribe a generic when it's available, mail-order pharmacies will call or fax back for permission to make the substitution. Physicians can eliminate this step by writing a generic prescription in the first place.

• E-prescribe. E-prescribing eliminates many of the issues that necessitate follow-up phone calls and faxes. For one thing, there's no chance of illegible prescriptions. But it also helps mail-order pharmacies save time on generic alternatives.

"As you sent a prescription in, [Medco's system] would immediately message you and tell you, 'Listen, there's a [generic] available. How about this one?'" explains Castle. "You can do that transaction immediately instead of having to go through faxes and phone calls."

Partner with your patients. There's nothing wrong with patients taking an active part in their own care. Ask patients to come prepared with information about their formularies and prior authorization, so you can be sure what prescription will work best under their coverage.

Also, patients using mail-order Internet sites can print out a list of their currently prescribed medications and bring it with them to their next visit. "The doctor can see what other doctors in that network are prescribing for [the patient] and can identify what might interact," says Jennifer Leone, a spokesperson for Medco.

That can be especially useful with older patients filling prescriptions from multiple doctors. According to Medco's data, the average senior in the Medco pharmacy benefit management plan takes nine different medications in a year, and one in 10 seniors sees at least six different physicians.

"You may have two different doctors prescribing the same medication and not knowing the other doctor is prescribing it," says Leone.

A silver lining

Lorenzen insists that there is a positive side to mail-order pharmacies: After some adjustments, practices might actually save time.

Because many mail-orders fill 90-day prescriptions instead of the usual 30-day supply from traditional pharmacies, practices should eventually see a decrease in the amount of phone and fax traffic about prescriptions, at least for existing patients.

"[Practices] don't get as many calls from pharmacies on a daily basis ... and faxing is pretty much the standard way of dealing with prescription refills," says Lorenzen. "So it sort of relieves them. [Practices] are feeling they have more time because they don't have as many phone calls to return."

Robert Anthony can be reached via editor@physicianspractice.com

This article originally appeared in the October 2005 issue of Physicians Practice.