OUTLOOK

The Future of Pharmacy

Patient-Centered Pharmacy
Cassandra Shields represents one of the new faces of pharmacists focused on the future
By Kelsea Nore

Cassandra Shields knew she wanted a career in the medical field. Shields ruled out getting an M.D. or D.O. on account of the long hours and the very real threat of malpractice that medical doctors can face. She had also considered nursing, the same occupation as her mother. Her path changed when, as an undergrad at Bethany College in Lindsborg, Kansas where she studied Biology, Shields interned at Apotek Pharmacy. It was there that she discovered that the pharmacy profession provided opportunities to develop lasting relationships that led to healthier lives for patients. It was very obvious that the patients trusted their pharmacists, and that the pharmacists sincerely wanted to help them, she said. Thats when I knew pharmacy was the profession for me. Reaching the Counter As a student in the University of Missouri-Kansas City (UMKC) School of Pharmacy, Shields enjoyed her

studies. Four years of classes, such as medicinal chemistry and pharmacotherapy, gives future pharmacists a strong foundation in understanding why pharmacists are considered one of the most trusted professions in healthcare. The first two years can be overwhelming. Everyone is saying How do I retain all of this knowledge?! However, internships and hands-on experience really showed us how much we already knew and how much we did retain from the classroom, she said. Pharmacists are almost considered to be a little obsessive compulsive, because if we do not perform our job to the best of our ability, we are putting our patients at great risk. Our job as pharmacists is to put the pieces of the puzzle together to see the bigger picture, she said. To this day, I use those ideas to motivate me to better understand, and further help, my patients. The 2010 graduate added, Leaving school doesnt mean your education is finished. Its important to stay up-to-date on whats happening in medicine and in

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OUTLOOK
your community. Utilize the Internet, conferences and communicate with your peers. Youll be amazed at what happens when people come together to help others. Starting Out Shields worked as a technician at the Olathe Medical Center Pharmacy in Olathe, Kansas throughout her graduate studies. I actually worked in hospital and compounding settings before considering retail, Shields said. It was a valuable experience; working closely with the doctors and seeing the immediate impact of my work was great. But, Shields reflected on what initially drew her interest to pharmacy, the ability to give continual care to patients by getting to know them well. Independent pharmacy was a better fit for her. Shields said that many national chain pharmacies have a different perspective on the pharmacist-patient relationship. Shes right, too. Many national chain pharmacies have incorporated strict time limitations on their pharmaciststhe infamous promise of Prescriptions in 15 Minutes or Less comes to mindthat seriously endangers patient care. A 2011 study released by The Mayo Clinic reported that more than 50% of people take medications improperly. Rushing patients out of the pharmacy does not serve to improve these statistics. Community Pharmacy Regional chain and independent pharmacies do not enforce these kind of stringent guidelines on pharmacists. Its really important that patients understand the significance of adherence and that were able to make time for patient questions and concerns, Shields said. The patients here at Key Rexall Health Mart in Salina, Kansas know that they can call or come see us with almost any health-related question. But not all patients realize this, and nor do their doctors. One of the biggest surprises for me as a community pharmacist was the disconnect between the doctors and the pharmacists, she said. For example, MTM (Medication Therapy Management) is a requirement of Medicare Part D, and it helps reduce costs. MTM is proven to be effective and it has a positive impact on the big picture for our patients, Shields explained. Ive had to explain this development to some physicians and make it clear to them why their involvement is so critical for the success of the patient. These kinds of team efforts between doctors and pharmacists have been proven as a successful, outcomebased disease-management method. This level of care is not only the most ethical course of action for health care professionals like Cassandra Shields, its likely the future of pharmacy, as well.

The Future of Pharmacy All levels and specialties of pharmacy are changing. According to the 2011 Advanced Pharmacy Practice Report to the U.S. Surgeon General: Current pharmacy practice is considerably more diverse than what has been previously reported in terms of scope of practice and practice setting. Traditional roles of the pharmacist tied solely to medication product and delivery have been greatly expanded.

Our patients know that they can call or come see us with almost any health-related question.
Cassandra Shields, Key Rexall Health Mart

Shields agrees. The days of making a living strictly with dispensing are over. Eventually, we may even see a flat rate for drugs, with reimbursements based on adherence rates or other services instead, she said. In the meantime, the move toward outcome-based care is inevitable, and I believe pharmacists should gladly embrace this change. Several studies and the forecasted changes dictated by the Federal Healthcare Reform bill point in this direction. Provisions within the Healthcare Reform bill visualize expanded MTM grants with funding for independent pharmacies and changes to the generic drug reimbursement standards as well. Legislation is not the only driving change within the world of pharmacy; technology has moved the profession into new realms as well. For example, patient adherence scores will likely be monitored digitally to calculate outcome-based results. It is not hard to imagine the benefits of medically trained professionals having access to and communicating these results. Pharmacists have a responsibility to their profession, Shields said. Were often the most approachable and accessible members of our patients healthcare team, and we need to let our patients, and their doctors, know this. By working togetherwith each other, doctors, nurses and other medical staffour patients can have happier and healthier lives. Cassie Shields, PharmD, lives in Salina, Kansas with her husband Brad Shields and their two Cavalier Spaniels, Max and Asher.

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Redefining Managed Care

No one is better positioned to changed the meaning of Managed Care than community pharmacists

By Kelsea Nore

For community pharmacists, Managed Care is a loaded term. While the idea of Managed Care inarguably looks good on paper, it has repeatedly failed to meet its own marks in practice. Its hard to argue with the idea of organizing the process; of bringing accountability and a case for financial liability to a healthcare delivery system that operates for the majority of people. However, there are several strings attached to Managed Care organizations that dont fit the proposed model for better healthcare. These strings include inflated administrative costs, self-serving formularies, and most importantly, the increasing affect of Pharmacy Benefit Managers on provider-patient relationships. Concerns about Managed Care organizations can be seen on all levels and within almost all professions in the realm of healthcare. For example, the University of Washington School of Medicines Ethics in Medicine Topic and Research guide recognizes and teaches that managed care is structured around a variety of incentives to

encourage the practice of cost-effective medicine, and to minimize variation in clinical practice patterns. Monetary and nonmonetary incentives raise the ethical concern that physicians may compromise patient advocacy in order to achieve cost savings. In effect, the Managed Care model may threaten to rush patients through their examinations, which may negate the farther-reaching healthcare goals of fewer treatments and better care. Pharmacists deal with these concerns frequently, and typically on a more frank basis than their prescribing physician counterparts. Patients dont blame their doctor when theyre told that their prescriptions either cant be filled or arent covered by their insurance. They blame the pharmacist, even if theyre informed that they need to contact their insurance companies or their employers Human Resources officer about their concerns. Theres still hope for the idea of Managed Care and pharmacists function in it. As an industry, pharmacy is changing. By adapting to new opportunities and making

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a group effort toward revitalization, pharmacists can not only help redefine Managed Care, they can also more clearly define their role as the healthcare providers they trained to be and arenot just people who can count to 30, in the words of Express Script CEO, George Paz. What is Managed Care? The definition of Managed Care changes according to who uses it and how. The meaning is different when corporate purchasers or directors of healthcare apply it than when pharmacists and physicians use it. Managed Care has one meaning to government regulators and another one entirely to patients on the receiving end. For many Americans, the term Managed Care is simply one among many that they associate with their health insurance plans. But what does it mean, exactly? Even the United States Department of Health and Human Services (HHS) recognizes the malleability of the term in Peter R. Kongstvedts HHS-approved book The Managed Health Care Handbook, saying that managed care is discussed more often than it is defined. Perhaps this is because managed care is used variously and eludes clear definitions. However, Kongstvedt (and the HHS) surmise that managed care refers, in general, to efforts to coordinate, rationalize, and channel the use of services to achieve desired access, service, and outcomes while controlling costs. But is that all? Using the most common present day method to investigate, and the one most likely to be used by your patients, one of the first and most credible definitions to come from a Google search is courtesy of The United States National Library of Medicine (NLM), a division of the National Institutes of Health (NIH). The lengthy but encompassing explanation from the NLM states that Managed Care programs are:

Community pharmacists are a fundamental part of the healthcare process, which is why you must be active in redefining the term Managed Care to create a better future for your professionand your patients.

intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases. What is clearly missing from the various definitions and explanations of Managed Care is the most commonly agreed upon principle

of pharmacuetical healthcare management: If patients correctly take their prescribed medications for their particular disease state(s) and if they adhere to the proper medication therapy protocol and if they have their medication therapy monitored correctly, then patients have a much greater probability of avoiding the need for acute and/or palliative care. In other words, if patients take the right medicine and take it properly then they will stay out of the hospital, which will, in turn, cut down on both short-term and longterm medical costs. Community pharmacists are an integral part of that process, and

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By adapting to new opportunities and making a group effort toward revitalization, pharmacists can not only help redefine Managed Care, they can more clearly define their role as healthcare providers

that is why they must be active in redefining the term Managed Care. No one is better trained to actively engage these practices into their profession, or has more to gain from their inclusion, than community pharmacists. History of Managed Care Historically, the idea of Managed Care dates back to the early 20th century. Early programs operated as a sort of co-op health plan for various unions across the United States. Henry J. Kaiser, a notable early user of a Managed Care program of his own devising, created a program for the workers building the Grand Coulee Dam in Washington State. Mr. Kaiser saw the potential of providing prepaid healthcare programs for his employees and opened his popular plans to the general public. Conversely, the American Medical Association (AMA) was opposed to these plans and the control they had over peoples choice of providers. The AMAs efforts during the 1930s and 1940s were mostly successful. Many states created laws that banned plans run by consumers or plans that restricted physician choice, effectively halting the creation of new plans. It was not until the late 1970s and 1980s that Managed Care organizations came back into the national spotlight when the HMO Act of 1973 was signed. The act put millions of federal dollars toward the creation of HMOs and employers soon followed suit with their own programs. Managed Care and PBMs The term Managed Care has been

snatched up by the pharmaceutical benefit management (PBM) industry. The common consensus is that the PBM industry gained a footing in the 1970s when employers used benefits to incentivize employment opportunities. The PBM industry began as a go-between business that devised, negotiated and administered prescription drug benefits for health insurance plans. Today, PBMs make their profits through administration for the plans they manage. Until recently, a substantial portion of their income was made from manufacturer rebates and brand drug discount programs aimed toward prescribers. PBMs promised to pass the savings from manufacturer rebates on to the consumer or to the healthcare plan they represented. Too often, this was not the case, which lead to marginally low reimbursement rates for pharmacists and costly formularies (and co-pays) for patients and plan sponsors. However, since so many brand name drugs have gone generic in recent years, major PBMs are now attempting to wring their profits from the generic drug market. For example, a 30-count bottle of 10mg Bisoprolol costs the pharmacy $14.70 or $0.49/pill and the MAC reimbursement to the pharmacy is $13.50 or $0.45 per pill. By the time the pharmacy includes the cost for a cap, bottle, label, and payroll (and to say nothing of overhead costs, such as rent and utilities), the pharmacist has lost well over the $1.20 initial hit he or she took on the product. The best estimates of the total cost to fill a prescription, including overhead and labor are

roughly $10 dollars. Therefore, the true cost to fill this prescription is $24.70, and the pharmacy actually loses $11.20 filling this prescription. Too many PBMs have no obligation, legal or otherwise, toward transparency in their business practices for brand or generic drug spread pricing. Community pharmacies have met recent moves and mergers within the PBM industry with indignation. Organizations, such as the National Community Pharmacists Association (NCPA), state boards and PBA Health, have been heavily involved in different political efforts to create legislation to prevent the overreach of PBMs into the United States healthcare system. Now, more than ever, we must maintain a strong and unified front to ensure that a high level of patient care remains the trademark of independent pharmacy, said PBA Health Texas Governmental Affairs Director John Heal. Attacks to the profession come daily and we must stand together in order to combat those attacks. PBMs have also been the biggest champions of mail order pharmacy (they stand to make the most money from this practice, after all). PBMs even go so far as to call their backroom Pharm.Ds Managed Care Pharmacists, which implies that every prescription is monitored, filled and followed up on a case-bycase basis. In actuality, Managed Care pharmacists address drug recommendations from a financefirst stance on the macroeconomic level, meaning that they do not meet or consult with individual patients and instead value the dollar first, the cure or relief of the patient second. Patients and physicians cannot easily reach mail order pharmacists should complications arise. Also, since patients receive their medications in larger amounts, such as 90-day fills, theres no sure way to monitor adherence. If patients arent taking their medication properly, or

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If you take the right medicine and take it properly you will stay out of the hospital, which will, in turn, cut down on both short-term and longterm medical costs. Community pharmacists are an integral part of that process

at all, any therapeutic benefit is lost. The Managed Care ideal of efficiency is thrown out of the window when the repercussions of mail order pharmacy are looked at logically, and from the patients point of view. Working Together Retail pharmacists have traditionally provided a multifaceted offering that is unique among healthcare providers. Yet, the fee-for-product (prescription drugs) model is no longer a sustainable way to do business for many pharmacies. Pharmacies have strived to make up for lost profits with items such as Durable Medical Equipment or OTC products, yet they still continue to struggle. With the import of PBM and federally defined Managed Care plans and the rise of computerized data and records, reimbursements have been severely reduced. It is imperative for pharmacists, no matter where they practice their profession, to take action to more carefully and boldly define their role in the healthcare spectrum or be relegated to flat rate, zero or even negative reimbursements for both the products and services they provide. How can pharmacists take back control of

their profession and help redefine Managed Care? Pharmacists must first fight professional apathy. Absolutely nothing can be done to expand and advocate the pharmacists role in outcomebased, total-patient care if those whom the movement is centered on do not prioritize these changes. Every pharmacist should be aware of his or her responsibility to give something back to the profession and be not only proud but also willing to pay it forward for the future of pharmacy. Attending conferences and legislative or community events is a good way to stay involved and informed on pending changes and new ideas. There are several state and national organizations that support independent pharmacy businesses. Pharmacists should consider their membership in these associations and groups as an opportunity to expand their livelihood both as an individual business and as an industry. What You Can Do Individually I will embrace and advocate changes that improve patient care, is the sixth tenant in the recently revised AACP Pharmacists Oath. Large group efforts arent the only way that pharmacists can expand on their roles as healthcare providers. The effects of Medication Management Therapy (MTM) have been widely espoused by pharmacists. In-store wellness classes and disease education forums have also had a growing affect on the growth of independent pharmacy. Community efforts such as The Diabetes Ten City Challenge (DTCC) and the Asheville Project in North Carolina are changing the definition of Managed Care, too. These projects established measurable practices for pharmacists and incentives for patients with varying diabetic disease states to participate. For example, the average total health care costs were reduced annually

by $1,079 per patient compared to projected costs if the DTCC had not been implemented. The first rollout of the Asheville Project (which initially focused strictly on diabetics) found that positive results were realized by month six and have remained fairly consistent from that point forward. Positive results were definitely seen by the end of year one with every program. Emulating a similar project or program within even smaller communities could significantly expand the independent pharmacists role in Managed Care. Pharmacists must then focus on one group. It is the largest, most important, and the potentially loudest group of people anyone in a healthcare profession will interact with: the patients. In turn, the patients can reach out to the payers (their employers and insurance companies). Explain the importance of staying connected to ones own community. This should be deeply stressed to your patients. Large, corporaterun pharmacies have no ties or obligations to the areas they serve. Business decisions are handed down to them from afar and are not made with the best interests of the community in mind. Remind your patients about the community pharmacys standards of genuine concern for their familys health and well-being, the personalized care and the attentive staff, too. Community pharmacists are well positioned to redefine the term Managed Care and make it a concept that works in both theory and practice with real, outcome-based results. By taking a firm, united stance against major PBM regulations by creating measurable wellness and prevention services that yield favorable results, and by asking for the voices of patients to chime in for these advocacy movements, there is no reason that pharmacists cannot redefine Managed Care.

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Pharmacist-Physician Relationships
Develop a professional relationship with the physicians in your area and watch your business grow
By Kelsea Nore

The April-June edition of the Journal of the National Medical Association carries the reprint of a speech given by F .W. Raglan, RPh., at the Alabama Medical, Dental and Pharmaceutical Association Meeting. Let the physician and the pharmacist come into closer relationship with each other, work for the good of each other and all concerned will be better off. Raglan delivered this speech in March 1909more than 100 years ago. The matter of the pharmacist-physician relationship is still as relevant today as it was in the early twentieth century. When youre able to clearly communicate with physicians in your area, you gain a valuable advantage for your business and even better, you can help your patients achieve optimal health outcomes. Common Barriers Successful, open and frequent communication between healthcare professionals is the best way to not only avoid the frustrations that accompany busy schedules, but it also fosters an environment of respect. When both physicians and pharmacists value the others expertise, they are better able to treat patients. A major barrier in the creation of strong pharmacistphysician relationships is the fact that physicians and community pharmacists work in physically separate environments. Because of this division, their interactions are rarely face-to-face and each fails to understand what the typical day-in-the-life of the other is like. Negative stereotypes about what the other does all day, such as shes just counting pills, needlessly flourish without an empathetic understanding of each others practices or businesses. Ignorance isnt the only issue preventing the formation of these important relationships. Many negative confrontations between pharmacists and physicians occur because of a lack of time. Pharmacists and physicians (and nurses and technicians) are all extremely busy.

When theres a prescription error, a hard-to-read script, or a possibly dangerous interaction, a consultation is necessary. Unreturned phone calls or long hold times are frustrating for anyone, but doubly so when a patient feels pressed for time as well. Healthier Patients If patients are directly referred by their doctor to your pharmacy, there is a better chance that they will follow the doctors orders and pick up their prescription. When theyre doing that, they may have questions about their medication that their physician was unable to answer but that you are more than capable of answering.

Let the physician and the pharmacist come into closer relationship with each other, work for the good of each other and all concerned will be better off.
Or, perhaps patients have some maintenance concern such as lifestyle or diet changes, or long-term care issues that they are addressing with you (who they associate with their medication), but not their physician (who they associate with examinations, surgeries or other clinical treatments). Pharmacists records are more likely to have a patients information and prescribed treatments from both primary care and specialty physicians, which paints a broader picture of the patients medication history.

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The mutual benefits of building a strong professional relationship with the physicians (and nurses) at the clinics and hospitals in your area are obvious to your patients; these working relationships reassure their already deep trust in their healthcare providers, which can lead to healthier outcomes. Healthier Business Your friendly association with local doctors and nurses not only makes your patients healthier it can make your business healthier, too. Mike Bellesine, R.Ph and owner of El Dorado TrueCare Pharmacy in El Dorado, Kansas, understands the inherent value of creating strong relationships with local physicians and the nurses and PAs on their teams. We have a reputation among local physicians as being very easy to deal with. Many chain pharmacies have corporate policies that make little sense and only result in increased headaches, Bellesine said. But before we implement any new policies, we carefully consider whether theyre really needed and what their true impact will be. One example of this forethought is El Dorado TrueCare Pharmacys delivery service. The delivery service isnt just for the patients who need extra care; it has a positive impact on El Dorado physicians and their office staff. If a doctor forgets to sign a Schedule II controlled substance prescription, most pharmacies would simply force the patient to return to the doctors office to have the prescription signed. At our pharmacy, however, well usually have our delivery person take the prescription over to be signed. Bellesines simple solution benefits the patient, the physician and the pharmacist. Creating and implementing services that big box or national chain pharmacies are unwilling to provide is another valuable ability. Being on-call 24/7 is another special feature that El Dorado TrueCare Pharmacy offers physicians (and patients). Local doctors know they can call us at home if they have a patient in need, even during holidays or weekends when other pharmacies are closed, Bellesine said. We dont limit this service to just our patients as we have found this to be an excellent tool to start developing brand loyalty to our pharmacy. Bellesine added, We promote the fact that they can call us with any pharmaceutical-related question and we will drop everything and research it for them, sending them any relevant articles and web reference sites. Physicians who know that youre ready and willing to answer their questions about medication are far more likely to ask you those important questions (and answer yours as well). A back and forth relationship is a healthy one to have.

Mike Bellesine, R.Ph and owner of El Dorado TrueCare Pharmacy in El Dorado, Kansas, understands the value of building and maintaining a strong pharmacist-physician relationship. Marketing Your Pharmacy Specialty services and programs and exclusive arrangements with local physicians are great ways to build relationships that help improve your pharmacy business. However, the physicians and nurses at the clinics and hospitals in your area will never know about what youre doing unless you tell them! Introducing yourself to physicians is the first step. The next essential step is marketing your pharmacys services. This is a surefire way to expose your business to physicians and patients. Creating materials that give a clear and consistent message about who you are and what your pharmacy offers is a fundamental business practice, and PBA Health can help. Call 816-245-5700 to learn more about how marketing your pharmacy will improve your business. A question were always asking ourselves is, What do we want to be when we grow up? Bellesine said. We think about what we can do to stand out, how we can honestly help our patients and bring in new customers, too. Giving is what makes us different. When we offer new services and go above and beyond expectations, were growing in the right direction.

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OUTLOOK

The Future of Pharmacy

The

Rise of

Pharmacy Schools
By Kelsea Nore

And what that means for your community pharmacy...

The expansion of pharmacy schools in the United States has caused alarm for many people in the profession. Major concerns are centered on the establishment of proper resources like educational faculty and staff in these schools and their sustainability. Available sites for rotation and residency are another concern. The increase in pharmacy schools will also have an effect on the many economical changes that will likely occur in the near future, such as healthcare reform and job market saturation. Most importantly, there are concerns about how the high number of pharmacy school graduates will learn about and respond to the numerous changes predicted in the future of the profession. Pharmacy is quickly becoming far less focused on strictly dispensing medication and is instead working toward direct pharmacistinvolvement in the healthcare team of each patient. By The Numbers Many believe that this increase in pharmacy schools was a direct result of the pharmacist shortage in the 1980s and 1990s. Another driving factor in the growth of pharmacy schools is the fear of another shortage brought on by the impending retirement and aging of the Baby Boomer population, a sub-group of future patients numbering approximately 76 million men and women. But, many also believe that its not the population numbers that gave rise to so many new schools of pharmacy. Instead, its the numbers that make up the amount of tuition dollars. A 2010 opinion article in the Connecticut Post written by former American Association of Colleges of Pharmacy (AACP) president Nicholas G. Popovich said that Pharmacy school tuition can cost anywhere from $100,000 to $350,000 depending on the program. The broad appeal of the pharmacy profession to students and the high tuition rate make the implementation of pharmacy schools at private and for-profit universities noteworthy. Popovich continued, We believe that these academic institutionsare creating pharmacy programs to take advantage of the premium tuition students must pay to earn a pharmacy education. As of February 2012, there were 129 accredited (full or candidate status) schools of pharmacy in the United States. In July 2010, there were 115 similarly accredited schools. In the mid-1980s, the number of

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ACTIVE INGREDIENTS

Quality Management
How recent U.S. legislation covers quality control in the drug supply
By Kelsea Nore

An estimated 80% of all prescribed medications in the United States are for generic drugs. This percentage is expected to continue to rise as more brand name drugs lose their patents in the coming years. A huge percentage of the active ingredients in generic drugs originate outside of the United States, namely in countries such as China or India. For the Federal Drug Administration (FDA) to monitor the hundreds of drug manufacturing centers requires substantial overhead and personnel. Recent legislation by way of the Congressional and Executive reauthorization of the Prescription Drug User Fee Act (PDUFA) includes the Generic Drug User Fee Act (GDUFA) Amendment. This critically important piece of legislation is a meaningful opportunity to continue to develop the structure of prescription drug safety and quality in the United States. Legislative Results Originally introduced in 1992 and passed in 1993, the Prescription Drug User Fee Act or PDUFA was created in response to drug companies frustrations over the long waiting periods they encountered during the FDA drug approvals. The administration was understaffed and underfunded and in turn, unable to handle the amount of drug reviews presented to them. PDUFA authorizes the FDA to collect fees from the drug manufacturers that produce certain human drug and biological products. Since the initial passage

of PDUFA, user fees have played an important role in expediting the drug approval process. An April 2012 Washington Post article reported that the new funding stream from pharmaceuticals has reduced FDA drug review times by nearly half...the average approval time dropped from 27 months to 14 months. The annually collected monies under PDUFA are application fees, establishment fees and product fees. These user fees from the drug companies made up nearly 62 percent of the United States 2011 drug budget, which is approximately $931 billion dollars. To date in 2012, PDUFA user fees have provided $702 million to the FDA (less than 1% of the combined 2010 net profits of the top ten largest pharmaceutical companies), according to a study published by the Union of Concerned Scientists. Signed on July 9, 2012, the fifth reauthorization of PDUFA, specifically in terms of the GDUFA Amendment, addresses the considerable regulatory challenges that new generic products have introduced into the healthcare industry. Concerns about foreign inspections and the rising number of ANDAs (Abbreviated New Drug Applications) are addressed. In a testimony before a U.S. House of Representatives subcommittee on health, Dr. Janet Woodcock, M.D., Director at the FDAs Center for Drug Evaluation and Research through the Department of Health and Human Services stated that The [GDUFA] proposal focuses on quality, access and transparency. Quality means ensuring

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Purchasing your generic products from a reputable, reliable source like the PBA Health Warehouse is one more way that you can personally help ensure quality for your patients.

that companies, foreign and domestic, that participate in the U.S. generic drug system are held to the same consistent high-quality standards and that their facilities are inspected biennially, using a risk-based approach, with foreign and domestic frequency parity. Generic Quality Concerns about quality often touch on the tiny differences between generic and brand name drugs. The generic must be bioequivalent, which means that the generic drug must have the same active ingredient(s) as the brand-name drug (also known as bioequivalence), the same labeled strength, and the same dosage type (i.e.: pills, patches or liquids). Bioequivalence can be measured in the time it takes for the generic drug to absorb into the bloodstream and the concentration of the active ingredients upon arrival. To pass FDA standards, the generic version must deliver the same amount of active ingredients into a patients blood stream in the same amount of time as the pioneer drug. However, the average difference in absorption into the body between the generic and the brand name is 3.5 percent. While all generic products must pass rigorous FDA active ingredient requirements, generic drugs do not need to contain the same inactive ingredients as the brand name product they mimic. Patients who report experiencing negative side effects when they switch

from brand to generic drugs or when their usual generic medication is switched out for a different manufacturers product may find that the issue is rooted in a difference in the binders, or inactive ingredients, used in the products manufacturing. Quality is important in any product one purchases for consumption but especially pharmaceuticals, said Nick Smock, pharmacist and CEO of PBA Health. Quality pharmaceuticals for a patient means the product will work in a similar fashion each and every time the medication is taken and look identical each time the prescription is refilled regarding, size, shape, and color. When you ensure that your pharmacys generic products are available and unchanging, youre providing an important, high-quality element of service for your patients. PBA Health Cares Purchasing your generic products from reputable, reliable sources is one more way that you personally can help ensure quality for your patients. Rick Mingori, Director of Trade Relations at PBA Health, adds, As part of our due diligence for product purchasing, we only work with manufacturers who have a history of consistent supply, quality products and fewif any GMP infractions. To learn more about how you can purchase quality products directly from PBA Health, call 816-245-5700 today.

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COMMUNITY PHARMACY

Your Pharmacy Needs an Adherence Program

By Kelsea Nore

An oft-cited 2009 study produced by The New England Health Institute (NEHI) estimates that in the United States close to $290 billion dollars is lost every year because patients dont take their prescribed medications or they take them incorrectly. The same study found that mortality rates among patients who did not adhere to their medications were nearly double the rates of those who took their medications as prescribed. A 2012 report from the World Health Organization (WHO) found that increasing the effectiveness of adherence interventions may have a far greater impact on the health of a population than any improvement in specific medical treatments. These findings add to the growing level of importance placed on preventive health measures and increasingly, the pharmacists who are moving to the front line as primary healthcare providers. As the Medicare Star Rating system and private insurance plans continue to develop, a system for monitoring outcomes and generating data is needed. With the Star Ratings system, were set up to co-exist with the PBMs. Were providing something that the PBMs and mail order pharmacies simply cant do. They cant have a face-to-face relationship with the patient. Any other method that they can come up with just isnt

going to work as well as patient-pharmacist interactions, said Justin May, Pharm.D., director of pharmacy at Red Cross Pharmacy, a regional community chain with locations in northwest and central Missouri. The 90-day mail order supply can almost defeat its own purpose because its the multiple points of contact that make the most difference. May continued, If were doing blood pressure checks at the pharmacy for patients who are diagnosed with hypertension and we do that for the first four months and get them on the right track, thats great. Creating, implementing and tracking an adherence program within your independent pharmacy isnt just a smart method of treating patients and keeping the doors open, its also a huge part of the future of the pharmacy profession. Adherence programs and the current healthcare environment are the opportunities pharmacists have been waiting for, said May. As a profession, we havent been aggressive enough. We go to school for years, have advanced degrees and then were told to stand behind a counter and fill or check prescriptions. Were trained to provide healthcare and clinical services to patients. Weve been waiting for years to make these changes. Its just a matter of starting.

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COMMUNITY PHARMACY

Justin May, Pharm.D., director of pharmacy at Red Cross Pharmacy, consults with an EliteCare patient who uses strip dosing to better manage her medication.

Good For the Patient The basis for the majority of adherence programs is synchronization. What this typically means is that multiple prescriptions are coordinated and made available for the patient to pick up on the same day. In turn, this creates an occasion for the pharmacist to examine all of a patients prescriptionswhich could be from several different physiciansfor possible interactions or for cost-saving opportunities. Potential refills are also called-in and made beforehand, eliminating exasperating waiting times for everyone involved. The Appointment-Based Model (ABM) adherence programs also include a monthly visit or consultation with the pharmacist. During this allotted time, patients can ask questions about their medications. Pharmacists can then offer recommendations for OTCs, diet or lifestyle changes or home health equipment. We start working on things a week in advance, said May, That way we can plan any refills you need, immunizations or a flu shotall thats pre-planned and communicated with you beforehand. Instead of sitting there waiting for your script to be filled, youre having an interaction with the pharmacist.

Thrifty White Pharmacy is an independent, regional chain of approximately 90 pharmacies based out of Minnesota. Dave Rueter, executive vice president of personnel at Thrifty White, said, Big problems create big opportunities for pharmacies that provide solutions. We have put a lot of effort behind improving medication adherence for our patients. A study done by Virginia Commonwealth University (VCU) of the Thrifty White Pharmacy organizations Med Sync ABM-based adherence program showed that a patient is three to eight times more likely to take their medication correctly using the program. The VCU Thrifty White ABM study also measured health costs for diabetics and found that by moving a patient from the 40-59 percent adherence level to 80+ percent adherence level, you can see a per-patient savings of $4,091 (a 31 percent decrease). When you consider that there are 25.8 million diabetics in the United States, the savings potential of a widespread ABM medication adherence program is astronomical. Good For the Pharmacy The Red Cross Pharmacy adherence program, called

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COMMUNITY PHARMACY
EliteCare, was launched in March 2011. Its a comprehensive patient care program and an organizational tool for the pharmacy, said May. And right now, our program is all in-store and managed very simply on our computers with a calendar and a spreadsheet for 12 stores. It was essentially started at no-cost. There are no financial reasons not to implement an adherence program. Another benefit of adherence programs for pharmacies is the time management capabilities. We looked at patients who had been on the program for over a year. The first thing we noticed is that workflow improved. Our average patient in the program has seven scripts, if you have 10 patients, thats 70 scripts and a pretty significant part of your day. May continued, Phone calls are also reduced because patients arent calling four to five times a week, and those calls arent generating another one to the doctor, but pretty soon, if theyre only calling once a week or once a month, you find yourself saving a lot of time. For time management, EliteCare is great. Improved workflow can also mean a more organized staff. Technicians, float pharmacists and other staff members can plan their shifts according to the busier days, or relegate their time on the clock to other tasks that need attention. An adherence program can also help lower the number of deliveries. Inventory management can improve when an adherence program is put into practice at a pharmacy. Knowing that you have an expensive medication on the shelf and a patient coming in every month to receive it gives you an ability to make smart purchases from your wholesalers. Simply put, running an adherence program at your pharmacy is good for business. I looked at prescription revenue and found that we were up 29 percent on the patients that had been on for a year or more, said May. Our total revenue coming in was 29 percent more from a year prior to them enrolling in EliteCare to one full year of being on EliteCare, and that was as a group. And, the numbers arent just because the pharmacies are refilling more often. Thirty percent of our people actually decreased in total revenue for us. It was that the other 71 percent increased significantly enough to increase our revenue by 29 percent. May continued, My gut feeling is that its because of management brand to generic changes or duplicate therapy that was eliminated. Where to Begin Some pharmacists talk themselves out of starting an adherence program because they believe that theyll

Adherence programs and the current healthcare environment are the opportunities pharmacists have been waiting for.
be overwhelmed. Truly, the first step is deciding to begin and committing to that choice. Its like personal finances, said May. If youve never done anything with your checkbook, of course its going to take some time to organize. Once you get on tracktypically two or three monthsyour adherence program is going to give you all the tools you need to have an organized day. May also advised that pharmacies start small. Choose five or ten long-time patients, family members or your staffpeople that you know will have patience while you iron out the kinks. Choosing physicians who you know are easy to work with is another great avenue of a successful start. Another component for success is getting your staff on board with the program. From the owner all the way to your part-time techs, if your staff sees and promotes the value of the adherence program, theyre even more likely to help you sell it to your patients. Everything we do is focused on the patient. Its all centered on providing care an we empower our staff to take care of the patient. Having our pharmacists engaged in the process not only makes sense, but also truly provides a win for all the parties involved, said Scott Hartwig, CEO and co-owner of Red Cross Pharmacy. Rueter added similar thoughts saying, Our advice to someone looking to implement adherence programs is that it needs to be a priority for the pharmacy. Enrolling a patient in an adherence program is just the start. Maintaining the program and communicating with the patients is an ongoing process that can get derailed quickly due to staff turnover, illness, vacations, and so forth. At the same time, it will increase your sales due to the increased number of prescriptions that actually get refilled. The effort is rewarding and will improve the health of your patients.

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OUTLOOK

The Future of Pharmacy

Pharmacy Exposed
An interview with author and pharmacist Dennis Miller reveals why the chain model doesnt work
By Kelsea Nore

Patients are growing increasingly unhappy with chain pharmacies. Retail pharmacists at chain drugstores are leaving their profession rather than be subjected to working conditions that are not only unmanageable, but also unsafe. Complaints about the fast-food business model for pharmacy have grown louder. With the implementation of the Patient Protection and Affordable Care Act setting the stage for preventiondriven changes on a national level, and an increasingly health-conscious public paying more attention to medical services and products, independent pharmacies are in a prime position to set the example for sustainable, practical healthcare in the United States. Want Fries With That? Former retail pharmacist and author Dennis Miller, R.Ph., is concerned about the pharmacy profession. I quit pharmacy after twenty five years because I was so fed up with slinging out prescriptions as fast as my hands and feet could allow, he said. A veteran of three major retail chain pharmacies, Miller published his book, Pharmacy Exposed: 1,000 Things That Can Go Deadly Wrong at the Drugstore in August 2012 to warn the public about aspects of chain store pharmacy that he believes are downright unsafe. Chains value a pharmacists speed in filling prescriptions far more than they value that same pharmacists drug knowledge or customer-friendliness, Miller said. The public needs to know that the chains have developed many metrics that measure how fast pharmacists fill prescriptions. These metrics put pressure on pharmacists to sling out prescriptions faster than most pharmacists feel comfortable in doing. Miller said. This can mean such things as overlooking potentially significant drug interactions or taking an educated guess when faced with a doctors poor handwriting rather than getting on the phone. From my perspective, Miller said, real-world conditions mean that the morale at the average independent

pharmacy is likely to be better than at the average chain drugstore. The attitudes toward customers and doctors at the average independent are likely to be better than at the average chain drugstore, too. Millers frustration with these issues has been echoed throughout the pharmacy world. Pharmacists have taken to the Internet to express their concerns about modern pharmacy practices on major websites and on their own blogs. Many of these aggravated professionals are relaying their experiences in national chain pharmacies. And, many are looking at independent pharmacies as a business model that promotes the health of patients... and pharmacists. Safety Measures The public needs to know that the biggest concern of many chain pharmacists is that they do not have adequate staffing for the safe filling of prescriptions, Miller said. Improper staffing makes for a long day without meal or bathroom breaks, and can lead to burnout and a high turnover rate among pharmacists working in chain drugstores. Many pharmacists feel like theyre rolling the dice every day when they go to work. Our constant companion is the fear that our next mistake might result in the death or serious injury of a customer, Miller said. Miller cited a July 2011 survey by the Oregon Board of Pharmacy that found that only 25 percent of chain store pharmacists agreed that their working conditions promoted safe and effective patient care, compared to the 76 percent of pharmacists working at independent pharmacies. Smaller, locally-owned, independent pharmacies often have a totally different culture from that at chains, Miller said. With the pharmacist-owner present most of the time, theres a stability at independents that is very often lacking at the chains; the pharmacist-owner not only has the power to keep good technicians, he or she can also hire an adequate number of them.

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OUTLOOK
Patient Satisfaction Pharmacists arent the only ones who seem to prefer independent pharmacies. A 2012 Pharmacy Satisfaction Pulse household study by Boehringer Ingelheim Pharmaceuticals Incorporated shows a substantial disparity between chain and independent pharmacies in customer satisfaction rates. Nearly 13,000 responders contributed to the survey. Of those who utilized chain pharmacies, only 62 percent were very satisfied compared to 76 percent of very satisfied independent pharmacy customers. A J.D. Power and Associates 2012 U.S. Pharmacy Study found similar results and noted a continuing decline in patient satisfaction with mail order services. The study cites: Overall satisfaction with mail order pharmacies averages 792 (on a 1,000-point scale) in 2012, down from 806 points in 2011. This compares with a satisfaction score of 814 for brick-and-mortar pharmacies this year, down from 818 in 2011. With a decline in patient satisfaction for both large chain stores and with mail order, independent pharmacies are poised to realign their image in the marketplace. When asked how independents can best compete against the big box stores, Miller said, Independent pharmacies should market themselves as a safer and more customer-friendly alternative to the chains. Healthcare First Independent pharmacies make the majority of their profits from prescription reimbursement. A study of community pharmacies prescriptions sales by UNCs Cecil G. Sheps Center for Health Services Research found that on average, Prescription sales constituted over 80 percent of their stores revenue for 9 out of 10 respondents. For 6 out of 10, prescription sales represented more than 90 percent of their retail business. Unlike independent pharmacies, most chain drugstores make their profits through front-end sales. Thats why many of them stock more shades of home hair color treatments than health supplies, or why the majority of large chains sell cigarettes or alcohol, Miller said.Its time for a major overhaul in pharmacy. Pharmacy needs to move toward a model that serves patient needs rather than corporate interests, and toward a model that places the health and well-being of pharmacy patients ahead of corporate profits. Pharmacy Exposed: 1,000 Things That Can Go Deadly Wrong at the Drugstore by Dennis Miller, RPh., can be purchased online through Amazon.com.

Dennis Miller, RPh., is a former chain drugstore pharmacist and author of Pharmacy Exposed. He wrote this book to warn others about the hidden dangers of the chain drugstore culture.

About the Author

How long did it take to write Pharmacy Exposed?
Believe it or not, I worked on this book for nearly 30 years. In many ways, Pharmacy Exposed is like a diary. To help me relieve stress, I would often go home after my shift and write about what I had seen at work that day. So, my book hopefully reflects the frustration that so many pharmacists feel from working in dangerously understaffed chain drugstores.

What are your hobbies and interests?

I am a political junkie and a news junkie. I spend far too much time online reading about politics and current events.

Where did you attend pharmacy school?

I graduated from West Virginia University School of Pharmacy in 1975. I worked in West Virginia and North Carolina.

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TECHNOLOGY
prescription records, making it easy for patients to manage their prescriptions online or to print off records to show their doctors. Many online refill solutions even allow you to set up text message or email refill reminders for registered patients. Besides making your patients lives easier, online refills can also streamline operations at your pharmacy. Fewer phone calls and online refills that go straight to your pharmacys computer system will help your pharmacists and technicians stay organized and it will free up time. Better adherence Online refills can also benefit your patients health-wise. Every year, more studies are released with data proving that medication adherence is a major driver to keep health-related costs down and to improve patients health. As it turns out, offering online refills is a simple and convenient method to encourage patients to adhere to their medication regimens. A 2012 study (Impact of an Online Management Account on Medication Adherence) published in the American Journal of Managed Care calculated adherence by measuring the proportion of days covered and found that the results indicate that patients who have utilized an online account have significantly greater medication adherence across 7 out of 8 therapeutic groups studied, as well as overall, compared with non-users. The same study also found that the users group had a higher proportion of patients achieving the 80% adherence mark, which can be crucial for chronic illness management. When patients have the ability to stay involved with their medication management and to do it at convenient times for them, their adherence rates and correspondingly, their health, improve. Business savvy Online refills arent just helpful for your patients, this service is also beneficial to your business. Patients are beginning to expect this kind of technology from their local pharmacyyou can bet national chains and big box stores already have it in place. Check with your pharmacys software vendor to find out the options for you. Many pharmacy software companies today offer turnkey online refill solutions that are compatible with your current system. Better yet, some even have options for smartphone apps, too. The American population is modernizingand fast. Community pharmacies that want to stay ahead are smart to embrace this new technology.

Online Refills
This technology can make everyones life a little easier
By Kelsea Nore

As a businessperson and a pharmacist, you know all too well that unfilled prescriptions and impatient patients waiting on their refills can be a headache youd rather avoid. To streamline the refill process, many community pharmacies offer automated prescription refills via phone, so patients can just call and refill their prescriptions by pushing a few buttons on their keypad. Now, they can do it with a few clicks of their computer mouse. As patients today become more technologically savvy, you have another refill option to consideronline refills through your pharmacys website. Added convenience A web-based refill service adds convenience for patients with 24/7 availability. They can refill their prescriptions at 2 a.m., 2 p.m., whenever. By just entering a few pieces of information, such as name, birthday, prescription number and contact information, your patients can quickly refill their prescriptions from their home computer, laptop, smartphone or tablet. Some online refill services even allow patients to create an account, so all they need to do is enter their username and password each time they want to refill their prescriptions. These accounts can even store patients

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OUTLOOK

How to Choose the Right Pharmacy Software

By Kelsea Nore

In your pharmacy, the computer is probably the one tool you use more than anything else. This multi-purpose machine is responsible for keeping your daily workflow smooth. But without the right software, your computer doesnt do much to help your day-to-day operations. You need software that works well and is easy-to-use. The right software can also be the difference between happy and unhappy patients. Whether youre thinking about switching to a different pharmacy software program or are currently faced with the task of choosing pharmacy software for the first time, you have several important elements to consider. First-time buyers Before you even consider the basic components of your computer, or the software purchase you need to make, you need to think about your pharmacy and the business

plan you have in place. Do you plan to expand and open more locations? What kind of pharmacy do you run currently? Have you thought about opening a different sort of facility, such as a long-term care pharmacy or a location focused on home medical equipment? Once you have determined the scope of your pharmacy software needs, you may also consider consulting your staff on their technological abilities. If your pharmacy techs are also tech-savvy, theyre likely comfortable with computers, but other employees might need more training. Lastly, youll want to spend time consulting with possible vendors. You want to find more of a partner, not just a vendor, said Heath Reynolds, director of business development for Speed Script, a pharmacy management systems and services provider. Knowing that your software provider is readily available for questions, concerns,

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Customer Service
More than just a department
By Kelsea Nore

The widest separation between the big box stores and independent pharmacies isnt size and it isnt cost; its customer service. Patients know that they will be treated like the valued customers they are at their local pharmacy, while their healthcare and medication needs are also met. A friendly, well-run pharmacy, staffed by technicians, front-end salespersons and pharmacists who genuinely care is often the difference that patients notice most when choosing a pharmacy. Good customer service matters. And, thats why PBA Healths customer service department works to provide true valueand great serviceto PBA Health customers. Meet Our Team For the past four years, customer service representative Tammy Howlett has inputted data, chronicling the previous days sales figures. These careful records influence every other department within the company, and help PBA Health team members make the best purchasing and inventory decisionsand pass those savings on to our customers. Its interesting to watch the growth that we have had over the years and to know that its because we provide great services for our pharmacy customers.

Its exciting to know that Im a part of this, Tammy said. This anecdote represents the kind of quality and hard work that the PBA Health customer service department performs every day. Tammy, like all of the PBA Health customer service representatives, handles incoming calls, orders and return authorizations on top of her designated responsibilities within the department, such as checking a pharmacys credentials and setting up appointments for the IT department to install software for customers. Glenda Masonbrink, who has been with PBA Health for nearly 10 years, helps handle the calls that are made monthly to ProfitGuard members and informs these customers about potential savings and purchasing recommendations. (ProfitGuard is PBA Healths primary supplier negotiation and purchase management service.) Rachel Cox monitors shipping and tracking for all PBA Health warehouse orders, often calling customers first thing in the morning to inform them of delays or shortages. Holly Morrison keeps careful records of necessary license re-verifications and also initiates FirstFill orders to get customers new products right when they come on the market. Christel Brushwood, the front desk recep-

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tionist, greets every visitor to the PBA Health office and answers phone calls to the main line. (Youve probably talked to her a time or two.) Managing the department is Brenda Wood, who has been with PBA Health for 12 years. While managing both the customer service and inside sales departments, Brenda also oversees ProfitGuard group setup and communication and sits on the Regulatory Compliance Team. Brenda is also the executive assistant to PBA Health vice president, Clark Balcom, COO. Second-in-command is customer service supervisor Jamie Dudley, who administers the day-to-day operations within the customer service department. Jamie also handles new accounts, completes audit requests for customers, and helps with the departments standard daily functions when needed. What We Can Do For You PBA Health understands that your pharmacys orders through the PBA Health warehouse are crucial to your business. Our customer service department works diligently to ensure that all of your questions about orders, delays, shortages and more are answered promptly and effectively. Our customers know that were always willing to go the extra mile for them, said Brenda Wood, customer service manager. A member of our customer service team answers every call made to PBA Health. Well take orders on the phone, via e-mail or faxwhatever works best for the customer. Not only can our customer service representatives help your business place and track orders, they can also help you run your pharmacy more efficiently. For example, product returns are an inevitable process in the pharmacy industry. The customer service department at PBA Health can help your pharmacy streamline the process by taking return requests in a number of different ways. Customers can call in their requests, fax them in, or submit them through our website at www.pbahealth.com. Once submitted, one of our representatives will promptly create a return authorization. In the event of a recall, the customer service department quickly informs all stores that purchased the product within the time frame specified. Customer service representatives then send letters via fax with instructions about what to do with the recalled product and where to return it. We send and collect all of the FDA-mandated recall responses, so you know that your bases are always covered, said Tammy. If the product needs to be returned to PBA Health, Tammy creates return authorizations for every store that has remaining affected product, but most of the time the

PBA Healths customer service department makes sure all orders through the PBA Health warehouse run smoothly.

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What do you like most about your job with customer service?
Brenda Wood Customer Service Manager My job is never boring! Every day brings its own set of new challengestheres always something going on. Luckily, I have a great team to help me out. Christel Brushwood Receptionist Im sort of the office mom around here, and I love that about my job. I field all the phone calls, I organize and order supplies, and I do what I can to ensure that meetings go smoothly. Brenda Wood, Director of Customer Service, looks over a ProfitGuard group order history. Glenda Masonbrink Customer Service Representative Its great seeing orders from new customers. It makes me aware of how the company is growing. We must be doing our jobs right! Rachel Cox Customer Service Representative The best part of my job is interacting with the customers. You really get to know people. It makes my day that much better when I get to talk to my favorite customers. Holly Morrison Customer Service Representative Every month we make calls to our ProfitGuard customers to let them know how the pharmacy is doing and it is nice to be able to catch up with them and form a relationship with them. It makes our jobs much more enjoyable and fun to do when a customer sounds happy to hear from us. Tammy Howlett Customer Service Representative I love talking to the customers. We make it a point to get to know our customers and oftentimes, those relationships help us solve their problems easier, too. Jamie Dudley Customer Service Supervisor My co-workers, of course! The customer service department works well together, and we know how to help each other out.

manufacturer requires pharmacies to return the recalled product to an outside third-pary returns company. CSOS, PBA Healths online CII ordering system, also helps pharmacies run their businesses more efficiently. And, you can count on our customer service representatives to help you out if you have any issues. With CSOS, you can avoid filling out endless paperwork while also ensuring that there are no errors that would require us to cancel lines. And, the orders arent limited to only 10 lines like on the paper forms, said Jamie Dudley, customer service supervisor. Other added benefits are that orders can be received next-day without the wait time of mailing blanks, and the regulated software keeps careful records so our customers dont have to. Making a Difference PBA Health customers know the difference that great customer service makes to their businesses. The customer service department is always there to help me out, said Ray Kirk, the head pharmacist at Noel Pharmacy in Noel, Missouri. They put forth the extra effort, and I appreciate that. Im told right away if, for example, an order is going to be late, and they even go the extra mile to investigate why and to figure out some other options for me. On top of that, theyre always friendly, which is important, too. The PBA Health customer service representatives eager and friendly demeanor matched with their considerable talents, are just a few reasons why our customers find that doing business with PBA Health is good for their businesses too.

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