Read on Twitter
1/ A 
In the US health care system, there is a frustrating phenomenon where there is a thing that makes sense, helps patients, & is demonstrated to work, even in the US, but can't scale due to the unique strangeness of the US health care system. https://twitter.com/amalec/status/1338224364089528320
In the US health care system, there is a frustrating phenomenon where there is a thing that makes sense, helps patients, & is demonstrated to work, even in the US, but can't scale due to the unique strangeness of the US health care system. https://twitter.com/amalec/status/1338224364089528320
2/
I've been nibbling at these issues for a while. Did a medication therapy management project for McKesson in the 00s. Worked on ACO-enabling pharmacy clinical integration. Did an eRx app. Ran R&D for a pharmacy switch. (Did drug development work & safety work, etc.)
I've been nibbling at these issues for a while. Did a medication therapy management project for McKesson in the 00s. Worked on ACO-enabling pharmacy clinical integration. Did an eRx app. Ran R&D for a pharmacy switch. (Did drug development work & safety work, etc.)
3/
So…I've seen things you people wouldn't believe.
So…I've seen things you people wouldn't believe.
4/
Let's start with the basics: can pharmacists even diagnose & treat? Nope, not in most places for most conditions. There are exception, when allowed by FDA, but mostly diagnosis & ordering are MD only.
Let's start with the basics: can pharmacists even diagnose & treat? Nope, not in most places for most conditions. There are exception, when allowed by FDA, but mostly diagnosis & ordering are MD only.
5/
So why is that? Well, MD lobbies, mostly & the US culture of medicine. But mostly the MD monopoly, & associated licensure & scope of practice rules by state.
But pharmacists aren't guilty of this right? Au contraire, pharmacists are *required* to count pills in most states.
So why is that? Well, MD lobbies, mostly & the US culture of medicine. But mostly the MD monopoly, & associated licensure & scope of practice rules by state.
But pharmacists aren't guilty of this right? Au contraire, pharmacists are *required* to count pills in most states.
6/
I mean, can't robots do that better than pharmacists? Sure, but the pharmacy lobby makes sure that pharmacist eyes are firmly on the dispense, double counting. Like a cybernetic organism.
I mean, can't robots do that better than pharmacists? Sure, but the pharmacy lobby makes sure that pharmacist eyes are firmly on the dispense, double counting. Like a cybernetic organism.
7/
So right off the bat, you have a problem: pharmacists can't diagnose & treat, & they don't have time to consult, because they have to be in every dispense, by law.
It's like we've designed the system so people can't work at the top of their license.
So right off the bat, you have a problem: pharmacists can't diagnose & treat, & they don't have time to consult, because they have to be in every dispense, by law.
It's like we've designed the system so people can't work at the top of their license.
8/
Then you've got store design issues. Really. In most pharmacies, dispense is done in the back, and you have to traverse aisles of candy, & soda & chips to get there. That's *by design*. Yes, you want people to pick up junk food on their way to their metformin script fill.
Then you've got store design issues. Really. In most pharmacies, dispense is done in the back, and you have to traverse aisles of candy, & soda & chips to get there. That's *by design*. Yes, you want people to pick up junk food on their way to their metformin script fill.
9/
So the space you might want for consult rooms reduces store real-estate for junk food which is the money maker. Yeah, if you get pharmacists doing consults, they are taking time away from dispense & space away from Twinkies.
So the space you might want for consult rooms reduces store real-estate for junk food which is the money maker. Yeah, if you get pharmacists doing consults, they are taking time away from dispense & space away from Twinkies.
10/
But let's say you work this stuff out. You want to bill for pharmacy consults for therapy management. Great. But pharmacies bill on NCPDP EDI standards to PBMs & consults are billed as X12 837 claims to the medical benefit.
But let's say you work this stuff out. You want to bill for pharmacy consults for therapy management. Great. But pharmacies bill on NCPDP EDI standards to PBMs & consults are billed as X12 837 claims to the medical benefit.
11/
Yep, we've got totally different payers & claim standards for medical vs clinical benefits. US health care, baybee.
Which raises a different issue. cui bono? Yeah, the patient, sure but nobody cares about the patient.
Yep, we've got totally different payers & claim standards for medical vs clinical benefits. US health care, baybee.
Which raises a different issue. cui bono? Yeah, the patient, sure but nobody cares about the patient.
12/
Reduce therapy: PBM
, pharmacy 
.
Reduce medical cost: payer
, PBM 
(except for MADPs & Star ratings, but they don't outsource that shit to the pharamcists).
Reduce E&M visits: physician
Finding a win-win is hard
Reduce therapy: PBM
, pharmacy .Reduce medical cost: payer
, PBM (except for MADPs & Star ratings, but they don't outsource that shit to the pharamcists).Reduce E&M visits: physician
Finding a win-win is hard
13/
& that's brings us back to the first tweet in the thread. Europe does pharmacy dispense, the Ashville Project showed pharmacists improve health outcomes, Kaiser, DoD & VHA do pharmacy consults, but more broadly?
& that's brings us back to the first tweet in the thread. Europe does pharmacy dispense, the Ashville Project showed pharmacists improve health outcomes, Kaiser, DoD & VHA do pharmacy consults, but more broadly?
