Plastic a grown threat!

(Is it too late to reverse the damage! Reduce rather than recycle. Recycle rather than trash.)

Tanvi Sharma: Unsplash

If we don’t act now, literally now, then even God cannot save us! Do we realize the damage we do to our environment every day of our normal life? I am going to focus this discussion on bottled water.

How casually do we drink water from a plastic bottle and toss it away anywhere? Look at the picture above! Isn’t there anything wrong or alarming with this situation? Landfills are getting fuller. One of the studies indicate that US has 58 years to not worry before they have to build additional facilities for landfills. Besides, plastic being not a biodegradable item or a very slow decomposing substance (takes about 1000 years to decompose), it’s actually contaminating our oceans and marine life. This has resulted in deaths of lot of marine life which in turn has affected the ecosystem.

Although, the modern ways of destroying or burning trash have revolutionized the whole aspect of pollution or environmental harm, there is a significant concern over consistency of these processes across the globe. In countries like US, the methane and other poisonous gases released are symphoned over to generate energy. This is great! But what about other countries! It’s a huge concern when it comes to resources and initiatives from a lot of other countries.

Recycling sounded like a solution for the last couple decades. Millions of Americans have been doing their due diligence in filling their recycling bins but recent studies have suggested that recycling of plastic or glass doesn’t make too much sense and that they would rather be disposed in trash! Sounds demoralizing right? Especially, common citizens like us, who have been thinking about this whole environmental damage and what will our generations go through! Some movies have shown how scary our future could be!

Recycling glass and plastic can actually be more cumbersome considering the economics. Plus the enormous quantity of water needed to clean up plastic and glass before they can be sold is worth considering! If glass bottles break, they can actually spoil the other good recyclable stuff, so then nothing renders recyclable.

China is a big factor in changing economics of recycling. China used to be the biggest importer of global recyclable goods. But now with the new trade situation, it’s not the same. Recycling goods cannot be sold at as cheap price as it was to China. Plus, studies have shown that China hasn’t dealt with plastic well and eventually plastic has ended up in our oceans.

As per this article,

“China’s ban may actually reduce the amount of plastic that ends up in the oceans,” he told NPR’s Planet Money podcast. “China was not very careful about what got into their oceans for a long period of time, and if some of the plastic piles were just too corrupted they could do whatever they wanted with it.”

Water- a natural resource! Why sell?

Markus Spiske: Unsplash

How did companies start selling water? It’s a free resource to mankind. God would be wondering too about this! Lol! There are people in so many parts of the world that don’t get clean drinking water and people are selling it in bottles. Here is something to make note of that says that bottles of fwater is no better than our tap water. Actually tap water goes through some regulations and checks that bottled water doesn’t!


15 Outrageous Facts About The Bottled Water Industry. “

“Water used to be free.

In fact, it still is — at least in nations blessed with plentiful clean tap water like the U.S. — but that doesn’t stop the world from spending over $100 billion on bottled water a year.” Continue reading…..

Final word: Please use your reusable bottle for carrying drinking water. Do not buy bottled water for two reasons: a) It’s supposed to be free. b) Prevents irreversible damage to the environment. C) Do not use disposables at home.


Use of CGM and control on diabetes

Source: iStockphoto

Imagine a patient who needs to check his/her sugar 10-12 times a day. To do this, patient has to carry the testing supplies with them at school or at work. Patients have to prick themselves multiple times, log their readings and then make adjustments on their insulin doses based on the readings. For type I diabetes patients or complicated type 2 patients, controlling blood glucose becomes very challenging in most cases. Subtle variations in diet, physical activity or emotional stress can change blood sugars instantly. So, in these cases, if the blood sugar is not checked and insulin dose not adjusted, patients can suffer from the unknown sugar level. These spikes or lows in sugar can be harmful. Highs can lead to ketoacidosis, lows can lead to hypoglycemia-both are life threatening conditions. This is why, Continuos Glucose Monitoring can be life saving.

CGM devices are fully automatic devices which give patients and their caregivers, alerts about highs and lows, thereby patients can take appropriate action about what dosage of insulin should be administered or not administered. There are patients on insulin pumps which can be programmed and synced with CGM devices. This enables appropriate automatic delivery of insulin based on patient’s blood glucose. Caregivers can even monitor patient’s blood glucose remotely. For example, a parent can constantly monitor his/her child’s blood glucose on the cell phone app or receivers from work when the child is at school. Studies have proven that CGM has significantly helped improve blood glucose monitoring and achieved much better control on diabetes. Now patients do not have to carry testing kits at work or school and don’t have to deal with the pain from several pricks a day!



Study results published in the Annals of Internal Medicine show that continuous glucose monitoring (CGM) systems can help patients with Type 2 diabetes better control their BGLs.

The study, which was sponsored by Dexcom, is the second arm of the DIaMonD study (Multiple Daily Injections and Continuous Glucose Monitoring) that reported findings on users T1D earlier this year.

After 24 weeks, Type 2 patients on multiple daily insulin injection therapy (MDI) who used the study’s CGM system lowered their average HbA1C levels from 8.5 percent to 7.7 percent. Patients with higher HbA1C baselines saw even more pronounced reductions — those with an A1C of 9.0 percent or higher saw an average 1.4 percent decrease. Meanwhile, the control group, which used fingerprick tests and a standard BGM, saw their average A1C levels decrease from 8.5 percent to 8 percent. While the gain from using a CGM may seem modest, it’s actually statistically significant.

“This arm of the DIaMonD study is one of the first to examine how well CGM works for people with Type 2 diabetes on MDI,” said Kevin Sayer, president and CEO of Dexcom, in a statement. “We are pleased to see a significant A1C reduction in this study, showing that the millions of people globally with Type 2 diabetes on MDI insulin therapy can benefit from CGM use.”

According to the study results, the A1C reductions occurred with minimal change in insulin dosages or dosing regime. Furthermore, CGM users also reported decreased time in hyperglycemia and increased time in their target blood sugar range compared to the control group.

Traditionally CGMs have been used with those with Type 1, but that trend may be shifting. In the study, CGM users reported high levels of satisfaction with the system. By the end of the study, 93 percent of the users were still regularly using the device, and they rated the benefits of the technology high and the hassles low.

Historically the approach is to give those with Type 2 an insulin and treatment regime until it begins to fail before adding more medication. Monitoring, in theory, would allow patients with Type 2 to have immediate feedback on their bodies and potentially avoid adding more medication.

Study participants ranged from 35 to 79 years old, with a mean age of 60. The study used the Dexcom G4® PLATINUM CGM System, which employs the same software as the current Dexcom G5® Mobile CGM System approved by the FDA for standalone use in insulin dosing.


Most insurances are covering CGM devices like Dexcom with a prior authorization from doctors. Some still don’t cover it because its not on their formularies. Some have it in their formulary but their criteria are very strict. These insurances require the patients to be type 1 only even though they have uncontrolled type 2 diabetes and are on intensive insulin regimen. Freestyle Libre system is also a good option for people who cannot afford Dexcom or Medtronic. Some DME pharmacies can also help these patients with their ability to bill medical plans.

Bottomline: If you have uncontrolled type 1 or type 2 diabetes, talk to you doctor about a CGM device. Your pharmacist can help you get it at at your pharmacy and train you on how to use it. Technology has also helped mankind and this is no different. As you read earlier, there are numerous studies that have shown CGM to be an effective tool to control diabetes.

Colchicine… a new aspirin!


A recent article from Medscape says that colchicine, being a very good anti-inflammatory drug helps reduce atherosclerosis and thus heart attacks. It’s believed that atherosclerosis is an oxidative process where arteries are blocked to the formation of plaques or blocks due to inflammatory mediators (obesity is linked to inflammatory conditions). Aspirin has been helping patients to reduce atherosclerosis by reducing platelet aggregation.

“Colchicine is a potent anti-inflammatory drug, and there is an accumulation of data suggesting that inflammation is relevant to the progression of atherosclerosis. The COLCOT study included 4745 patients who were recruited within 30 days of their MI. They all received two antiplatelet agents and a statin, and they underwent angioplastyif necessary. Then they were assigned colchicine at a low dose of 0.5 mg/day or placebo. The average follow-up was 23 months, and we found a 23% reduction in the primary efficacy outcome, which was the combination of cardiovascular death, resuscitated cardiac arrest, MI, stroke, or urgent hospitalization for angina requiring revascularization.”


The anti platelet effect of aspirin can be inhibited by NSAIDs so it’s important that NSAIDs be taken at least an hour administering aspirin. And consult your doctor if you take any NSAIDs. NSAIDs are not recommended for a longer term or regular basis. I wonder what’s the correlation between anti-platelet drugs and anti-sclerotic drugs like Colchicine.

Plaques in the blood vessels rupture over time and that’s how platelets flock in to clot the blood at the damaged area. So, I guess, colchicine, being a non- NSAID anti-inflammatory drug offers a pretty good option for CV patients, especially for the ones who also suffer from Gout. If no plaques, no platelets. I am pretty sure more studies on colchicine as a CV drug will enlighten all of us about pros and cons, risk-benefit and other facts.

Drought of antibiotics

(Beware of this epidemic)

Source: Adam Niescioruk/Unsplash

There was a time when people died of common bacterial infections. As decades and centuries past by, treatments became so easy. It feels like modern science has answers to all known infections. Then suddenly now, we have dragged ourselves to a horrific situation of “Drug Resistance”!

In today’s world, people want instant results. Whether it’s to get news updates on digital media, connecting to people all over the world in seconds, getting an instant coffee or buying instant food. What more! This behavior stretches to getting instant prescription too from a doctor, online consultation or even buying them directly from pharmacies without involving doctors. Antibiotics are abused day in and day out. We talk about opioid abuse because of its potential of habit forming and to kill people but antibiotic abuse is seldom addressed. There will be a day when people can’t find treatment to common infections like middle ear infections, strep throat or a UTI. We humans have been inflicting so many problems on ourselves by continuing to be frivolous.

People insist their doctors to write antibiotics as soon as they get sick. For example, a person with influenza demanding a friend physician to prescribe Zithromax or an Augmentin. Antibiotics are powerless against influenza and other illnesses caused by viruses. So when someone takes antibiotics for the wrong illness or uses too many too often, this kills off helpful bacteria that populate the body, threatening the delicate balance upon which health depends.

Drug resistance

If an antibiotic is given to a patient without actually diagnosing the infection, it might be a wrong antibiotic. Here is more on this issue of societal pressures, inappropriate use and diagnosis, agricultural use, hospital use- all contributing to more and more spread of drug resistant species:

“Societal Pressures

The use of antimicrobials, even when used appropriately, creates a selective pressure for resistant organisms. However, there are additional societal pressures that act to accelerate the increase of antimicrobial resistance.

Inappropriate Use

Selection of resistant microorganisms is exacerbated by inappropriate use of antimicrobials. Sometimes healthcare providers will prescribe antimicrobials inappropriately, wishing to placate an insistent patient who has a viral infection or an as-yet undiagnosed condition.

Inadequate Diagnostics

More often, healthcare providers must use incomplete or imperfect information to diagnose an infection and thus prescribe an antimicrobial just-in-case or prescribe a broad-spectrum antimicrobial when a specific antibiotic might be better. These situations contribute to selective pressure and accelerate antimicrobial resistance.

Hospital Use

Critically ill patients are more susceptible to infections and, thus, often require the aid of antimicrobials. However, the heavier use of antimicrobials in these patients can worsen the problem by selecting for antimicrobial-resistant microorganisms. The extensive use of antimicrobials and close contact among sick patients creates a fertile environment for the spread of antimicrobial-resistant germs.

Agricultural Use

Scientists also believe that the practice of adding antibiotics to agricultural feed promotes drug resistance. More than half of the antibiotics produced in the United States are used for agricultural purposes. However, there is still much debate about whether drug-resistant microbes in animals pose a significant public health burden.”


The situation is dire indeed: According to the newest data, more than 2.8 million people in the United States experience an infection from antibiotic resistant bacteria each year. Moreover, these “superbugs” cause 35,000 deaths per year in the country.

CDC has updated the estimated number of infections with antibiotic resistance per year from 2 million to nearly 3 million.”

The fact that so many bacteria are not responding to first- or even second-line treatments means that people with these infections face much higher risks and poorer health outcomes.

According to one recent study, “Of all antibiotics sold in the [U.S.], approximately 80% are sold for use in animal agriculture.”

Farmers have resorted to such high rates of antibiotic use in animals to boost growth rates and prevent infections, which are more common among livestock due to ways that producers handle these animals for breeding or as a source of meat.



  • Do not insist your doctors to prescribe an antibiotic without proper diagnosis.
  • For viral diseases infections, do not self-medicate with antibiotics.
  • Meat might cause and spread drug-resistance, so check labels before you consume.
  • Practice prevention habits rather than overly relying on antibiotics. Remember, there aren’t too many antibiotics in the pipeline of Pharma invention. We don’t want to have a Drought of antibiotics.
  • And of course, please get all vaccines available today to prevent illnesses. Your doctor or your pharmacist can determine your eligibility to get or not get a particular vaccine.
  • Book a consultation at to learn more on vaccines, drug-resistance and any other health related issues.

Medicare: A,B,C,D!

(It truly is about learning A,B,C,D…..)

With the introduction of Medicare Part D in 2006, we had four letters to remember A,B,C,D. To most seniors and people eligible for Medicare, it’s still a confusion. All they know is: “I have Medicare”. In markets like south florida, most people are not aware of the 4 alphabets. They are under the impression that they are covered completely just because they have Medicare! I am focusing this discussion of Medicare Part D or prescription drug coverage within Medicare. Its upto us, the pharmacists, nurses, doctors to educate these patients.

Pharmacists report to us that, beginning of the year is hell for them…lol! First of all, most people have changed their insurances. Then, their copays are a big surprise. Someone who paid nothing last year gets to hear that his new copay is $950 or $2500! WOW! So, then, my pharmacist folks wrok hard to find these patients financial assistance through foundations so they can get their medications. And believe me, the processes aren’t just click of a button.

A lot of Marketting is done by third parties or insurers offering Medicare plans including C and D. A lot of education and TV ads are targeting this population so they understand and make good choices during open enrollment. But the question is: why do these people have to suffer during the “coverage gap” or “donut hole”?

Donut hole


To a lot of people who are actually Medicare D beneficiaries and even HCPs, it seems like “donut hole” has something to do with donuts… lol! But it’s not. Donut hole is a coverage gap when these patients use up a certain amount (around 3700) after which they pay about 25% of the cost of the medication. This is where problems come in.

The first hurdle is that these patients cannot be offered copay assistance from manufacturers as per Anti- kickback law, manufacturers cannot incentivize any patient to buy medications that are paid by Medicare or Medicaid or Tricare. So with this law in place, a lot of patients can not afford the copays. As a result, they chose either not to fill their prescription or cut their doses in half to make one month supply last 2 months. Unless, they know hardworking, dedicated pharmacists who can help them with financial assistance from foundations, they end up being NON-ADHERENT! But foundations do not necessarily have funds all the time. Its like “first come first” basis and after the funds run out, the other patients are left unfunded or untreated.

Non-adherence: costing big

Source: Fierce healthcare

Stats reveal that non-adherence is a big liability on health care costs. While the original purpose of instituting the gap was to limit the cost of the Part D program, it has resulted in unintentional consequences.

Read this article which details how does donut-hole affect adherence, health outcomes and thus health care costs.

Imagine, scenarios like a patient with grade 4 prostate cancer not been able to afford his medications. In such cases, patients refuse to get their refills and call doctors for going back to infusion chemo which is so much more aggressive and give undesirable side effects. In some cases, where chemo is not a possibility, patients just let go the medicine and hope to get funds from foundation whenever its available.

For some disease states like Psoriasis or Atopic dermatitis, there are rarely any funds available through foundations. So, patients are either forced to change treatments or come up with thousands of dollars as copay per month. Middle class usually suffers in these situations.

Luckily, PAP or “patient assistance programs” are available with most specialty brand medications. But again, patients are not aware of these. It falls on HCP team to coordinate the patient with the manufacturers. So, a question comes to my mind! Why are manufacturers allowed PAP but no copay assistance. This is what makes Medicare a bit confusing.

Sticky situations come in when the medication is a generic and the patient is in donut hole or has high deductible in the beginning of the year. Moreover, if foundations have no funds, then what? PAP doesn’t apply since its a generic. Copay is unaffordable and no funds available. Pharmacists become helpless in these situations. Non-adherence is imposed on these patients.


  • A thorough understanding of Medicare plans is needed to help patients chose the right plan for them.
  • All pharmacists and HCPs need to be proactive to find financial assistance to avoid Non-Adherence and thus, mortality.
  • Medicare needs some thought about deductibles, copays and Donut-hole.
  • More generics need to hit the market so costs become affordable.
  • Generic companies should also have PAP programs.

Digital mentor: Positive outcomes

(Technology making a difference)

Source: Babyqb/unsplash

What a wonderful time we live in! All answers are right at your fingertips. There is hardly anything that’s a secret nowadays. Any layman who is savvy with his smart phone can get information about anything. I wonder how did we manage getting information about a decade ago. For purposes other than health, library and newspapers used to be our resort but for health related queries, we were helpless. Going to doctors everyday was not a viable option.

But today, everything can be found online or apps! If you want to know about symptoms of any disease, you can just search in seconds. What more that a friendly app can actually train you to prevent a disease! If you want to know anything about your medication, the information is at your fingertips! Drug-interactions, side effects and proper administration techniques are all available online or apps or YouTube. Some apps even monitor your physical activity and encourages you to stay fitter and healthier.

Gadgets like Fitbit can continuously challenge you to walk or run more miles. Devices like Dexcom can continuously report your blood sugar. Apps like Glucocious can train you about everything related to diabetes, it’s prevention and management. Apple’s health app monitors your steps everyday. Medscape is an online bible for medications. Then there are apps that can measure creatinine clearance, body composition, BMI, etc.

There are online resources to connect with MDs or pharmacists or other providers. So for minor ailments or quick questions, you don’t have to wait for your next appointment or drive to your pharmacist. For any medication related query, feel free to submit your query online at:

Some handy apps

Source: By Vera Gruessner on November 13, 2015,


Multiple Sclerosis:




There are tons of other apps that enable common men and women understand their diseases states in a user friendly language.



Mobile devices and apps have provided many benefits for HCPs, allowing them to make more rapid decisions with a lower error rate, increasing the quality of data management and accessibility, and improving practice efficiency and knowledge. Most importantly, these benefits have been shown to have a positive effect on patient care outcomes, as evidenced by a reduction in adverse events and hospital length of stay. These and other benefits mobile devices and apps provide to HCPs are discussed in the following section.

One major motivation driving the widespread adoption of mobile devices by HCPs has been the need for better communication and information resources at the point of care. Ideally, HCPs require access to many types of resources in a clinical setting, including:

  • Communication capabilities—voice calling, video conferencing, text, and e-mail .
  • Hospital information systems (HISs)—electronic health records (EHRs), electronic medical records (EMRs), clinical decision support systems (CDSSs), picture archiving and communication systems (PACSs), and laboratory information systems (LISs).
  • Informational resources—textbooks, guidelines, medical literature, drug references.
  • Clinical software applications—disease diagnosis aids, medical calculators.


  • Apps are only for reference purposes. They don’t not replace your doctor’s or provider’s diagnosis, clinical judgement, experience and treatment.
  • The information is very helpful to patients as well as HCPs. Alerts of errors, help stay current, provide most accurate information about dosing and dosing criteria, helps people understand their medications and disease states in user friendly language, facilitate communication and prevents delay of information.
  • Most importantly, it’s so handy, free and available whenever needed.

Celebrate “One step forward”

(A happy new year: in true sense)

Source: Nora Schlesinger/Unsplash

What does the New Year’s Eve mean to most of us? Celebrating the arrival of new year with food, drinks, friends, families….right? How about adding some value or meaning to this grand celebration! I mean what’s the point of welcoming new year if we don’t commit any changes for good! What’s the big deal about count down, looking at the dropping ball in Time Square! What’s the significance of sparkling skies with fire works?

Is it just about drinking and eating on the New Year’s Eve and getting sick with nausea and hangovers on the very first day of the year? That cannot be an ideal start to a new year!

A lot of people make some resolutions for new year. What’s your new year resolution? Be sure you are practical or realistic about making any resolution because resolutions are usually broken more often than applied. According to me, the true sense of celebrating new year should be to take One Step Forward towards a healthier and happier life. Because it’s this One step forward that’s gonna not only bring value to our lives but also inspire our children and younger generations to stay committed and healthier.

Here are some of the things you might want to Cut down or Add on, One at a time, so you don’t feel the burden from sudden change.

Cut down….

(Cutting down ONE is just a minimum. If you can, avoid these items for good.)

  • ONE coffee per day
  • ONE cigarette per day
  • ONE day per week of alcohol consumption
  • ONE meal per week of junk food (eat home made food or freshly cooked food from outside)
  • ONE hour per week of screen time
  • ONE plastic use per week (minimize use of bottled water)
  • ONE bad characteristic in your behavior like anger, jealousy, lying, cheating, etc. Trust me all of these are related to bad health.

Add on….

(Adding a minimum of ONE is a suggestion, not a rule. Feel free to add more than one if needed or tolerated)

  • ONE serving of fibrous food (vegetables and fruits) per week in your meal
  • ONE day per week of cooking fresh food at home
  • ONE day per week of physical exercise, if your doctor allows
  • ONE day per week of monitoring your blood pressure
  • ONE reading per day of your blood sugar
  • ONE hour per week of family time
  • ONE dollar per day to your savings (reduces financial stress on a long term)
  • ONE act of gratitude per week (reduces stress, anxiety, depression and other mental disorders)
  • ONE act of charity per year
Source: Michael Fousert/Unsplash

Celebrate the new year with a real meaning!

Don’t just celebrate the new year for name sake or to show off your lavish lifestyle or your grandeur villas or expensive clothes! Celebrate it with a sense of gratitude towards the past year and committing loyalty towards new year with all the good habits.

Feel accomplished for the past year and don’t forget to thank everyone (and even God if you are not atheists) who participated or contributed towards your success. If you haven’t accomplished during the past year, it’s still okay to thank people for challenging you and providing you those valuable feedbacks. And most importantly, commit the new year, about chasing your dreams with solid intent and hard work.

It’s said the “an aimless life is a miserable life”. So on the last day of the year, take a few moments to account for all the goods and bads in your lives and like an accountant, devise a plan for the next year how to reduce items in bad column and increase in good column, just like we try to increase our assets and decrease liabilities every fiscal year. To me, that’s a celebration in true sense. There has to be something special about so many humans getting together on one night- can’t be just superficial celebrations!

Finally, to all my family members, friends and well-wishers, I bow to you for all the good things you have blessed me with and I wish you all health, peace and prosperity.

Happy New Year! Have a blessed 2020 and also decades thereafter! New year, new beginning:

Source: Alexa Presa/Unsplash

Pharmacy benefit manager

(The power of the middle man)

Source: Pepi Stojanovski/Unsplash

To simply put in perspective, PBMs work for insurance companies to manage their drug costs, negotiate with manufacturers for better pricing and placing their drugs on preferred formularies versus others. By doing so, they eventually save money for insurance companies, promote drugs of companies who negotiated “good deals” or rebates and thus, make money from both entities.

This model is so lucrative for PBMs. Think about it. They don’t make drugs, they are not the insurers either but they get to control everything about prescription drugs and make tons of money being the middle man….lol! Caremark, Medco, Optum RX, Prime Therapeutics are some of the giant PBMs who control pretty much the entire country’s prescription business. Most insurances fall into these 4 PBMs.


Just money

It’s neither doctors, nor patients nor pharmacies- it’s a trio of insurance companies, manufacturers and PBMs that get benefitted for the most part!

Doctors are often unhappy when certain drugs are “not covered”. Some drugs need extensive “prior authorization” process for them to be covered. Some expensive drugs (medications for specialty conditions like oncology, rheumatology, dermatology, multiple sclerosis, etc.) require patients to pay extensive copays. In most cases, pharmacies help them to get copay assistance but sometimes unavailability of copay assistance make these treatments unaffordable. Thus these patients go untreated making doctors look unsuccessful.

Patients become victims of this complicated system. They get unpleasant surprises all the time in-spite of paying exorbitant premiums every month. They not only have to deal with complex disease states but also PBM led complications.

And of course, the pharmacies are not spared either. In a lot of cases, pharmacies dispense the drugs bearing a “LOSS”. Yes it’s unbelievable how PBMs force these pharmacies with such loss imposing contracts. It almost looks like pharmacies are at the mercy of PBMs. If pharmacies don’t agree their terms, they are out of network and won’t have any business. The contractual rates and reimbursements are so terrible that pharmacists are not seeing this as a prosperous business anymore. Even chain pharmacies have gotten a big hit from PBMs. The gross profits have gone down to bare minimum, so much so that the companies have stopped giving raises or bonuses to their pharmacists. Lack of transparency regarding rebates and DIR have created issues of mistrust and conflict of interest.

Read the following article from ““

The Need for Transparency with DIR Fees

By Christina Bennett, MS

“Pharmacy benefit managers (PBMs) have found a new way to manipulate pharmacies—specialty pharmacies in particular—for their gain with direct and indirect remuneration (DIR) fees.

The term “conflict of interest” has never really been more justly stated than when it describes the relationship between a PBM and a specialty pharmacy, said Jeff Vacirca, MD, Community Oncology Alliance, CEO, New York Cancer Specialists, in an interview with OBR. “It’s an atrocity,” he told us.”

Legit DIR Fees Have Become Warped

“Normally, after a drug is sold to a patient, PBMs and insurers receive additional compensation, such as manufacturer rebates, that produce a net drug price much lower than the list price. Under Medicare Part D plans, patient co-pays are calculated off the list price of a drug, not the lower net price.

Having co-pays calculated off the list price, which typically is inflated and not transparent, means neither Medicare beneficiaries nor CMS share in any cost-savings. CMS requires all transactions after the point of sale to be reported to CMS; these transactions are called DIR fees. CMS then uses the reported DIR fees to capture the true net price of the drug and calculate accurate payments to Medicare Part D insurers.

However, PBMs have misrepresented DIR fees to their benefit. Several months after a prescription has been dispensed, PBMs are charging fees to the specialty pharmacy that eliminate most, if not all, profit it may incur for dispensing the drug. Retail pharmacies are being hit by these fees as well, but mostly this practice is occurring within specialty pharmacy and with Medicare Part D plans.1,2

“A lot of PBMs own pharmacies, such as CVS Caremark that has its own specialty pharmacy, and they always keep saying, ‘well they’re paying DIR fees too’—but you’re paying them to yourself,” said Eric Dallara, RPh, pharmacist in charge of the dispensing pharmacy at New England Cancer Specialists.

Four national PBMs—Express Scripts, Inc., CVS/Caremark Corp., OptumRx, and Prime Therapeutics—control 80% of the prescription drug market and they each own a specialty pharmacy.1,3-6

Additionally, the four largest Medicare Part D plan sponsors—UnitedHealth Group, Humana, SilverScript (CVS Health), and Express Scripts—own or are affiliated with a PBM.2 Having PBMs and insurers so closely tied together is like taking money from one pocket and putting in another.2

Worse, PBMs do not always label fees as DIR fees; instead they use phrases like “network rebates” or “pharmacy performance payments.”1


Source: Brandon Mowinkel
  • Gag clause prohibitions: Gag clauses are provisions written into contracts between PBMs and pharmacies, prohibiting pharmacists from informing customers when the out-of-pocket (or cash) price for a prescription is lower than the medication’s co-payment, or whether a cheaper alternative is available.
  • Claw back legislation: “Claw back” requirements are provisions written in contracts that force pharmacies to pay back to PBMs and/or health plans the difference between a patient’s copayment and the negotiated drug price, when a patient’s copayment for a drug is greater than the price the PBM or insurer negotiated with the pharmacy. In 2019, SD and NE became two of the most recent states to enact legislation prohibiting co-pay “claw back” contract provisions. To date, at least 22 states have passed some form of “claw back” legislation.
  • Price gouging and price increasing reporting: Prohibiting manufacturers and wholesalers from engaging in “price gouging” which is defined as an unconscionable, excessive, unjustified price increase of an essential off-patent drug.

So, do we need PBMs? Unless PBMs become patient-centric and provide some relief to pharmacists, unless PBMs stop being opaque to their revenue flow, unless PBMs do not cater to one specific entity and avoid conflicts of interests, they WON’T be trusted at all.

Hypertension- simply ignored!

(A ticking time bomb leading to heart attack)

Source: Hush Naidoo/Unsplash

It’s said that “A good heart makes one a better person”.The thought holds true for health too! Heart can be affected by several abnormalities; some genetic and some acquired. One of the most common disease and also the most ignored disease is hypertension or high blood pressure.

First of all, it’s seldom realized by the patient, so he/she won’t even see a doctor till one day, a chest pain or breathlessness or sweating is felt while talking. In the worst case, these symptoms are multiple folds and the person experiences a heart attack.

While there are a few reasons to get a heart attack including emotional and psycho-social factors, hypertension is one of the known ones to cause it. Hypertension is mostly ignored because it’s mostly asymptomatic and even if it’s diagnosed, non-adherence to its treatment is seen in most patients.

In countries like US, where there is so much emphasis on prevention, hypertension is still one of the leading causes of deaths. People are educated but still don’t practice healthy living. Improper life styles, diet, stress and lack of physical exercise contribute to poor heart health and lead to hospitalizations and even deaths! There are a lot of people who keep living under the notion of negligence and that “I am never sick, I always stay healthy and I don’t need any doctor or medicines.” Some say “why should I go to a doctor when I don’t feel anything”. Some go to doctors and get a prescription but are too busy to fill the prescription in a pharmacy. Some fill the prescription but don’t take them. Pharmacies have made it so easy to help patients stay adherent by refill reminders, auto refills, text messages, 90 day fills but eventually, patients will have to assume the responsibility to live longer and healthier.

Staggering stats…

“High Blood Pressure in the United States

  • Having high blood pressure puts you at risk for heart disease and stroke, which are leading causes of death in the United States.1
  • About 75 million American adults (32%) have high blood pressure—that’s 1 in every 3 adults.3
  • About 1 in 3 American adults has prehypertension—blood pressure numbers that are higher than normal—but not yet in the high blood pressure range.3
  • Only about half (54%) of people with high blood pressure have their condition under control.2
  • High blood pressure was a primary or contributing cause of death for more than 410,000 Americans in 2014—that’s more than 1,100 deaths each day.1
  • High blood pressure costs the nation $48.6 billion each year. This total includes the cost of health care services, medications to treat high blood pressure, and missed days of work.”


Stats related to non-adherence

“The patients who didn’t take their medication correctly were also more likely to be admitted to hospital after a stroke. Their risk of hospitalisation was 2.7-fold higher in the second year after being prescribed anti-hypertensive drugs compared to adherent patients, and nearly 1.7-fold higher in the tenth year. In the year in which they admitted to hospital with a stroke, their risk was nearly two-fold higher than the adherent patients.”


People often take it so casually because they may not be aware of the consequences. In most cases, one has to take just one pill a day and monitor it 3-4 times a week. That’s it! If we cannot find time to do this bare minimum task to keep us alive, then even god cannot help us. It’s about being responsible to ourselves first…right? I hear from people all the time saying that I am alright and I don’t need any pill…lol! I mean, you might be alright but have you measured your blood pressure? There are non-pharmacological ways too to maintain your blood pressure but the key is to monitor it regularly and keeping a log. In extreme cases of unstable blood pressure, it’s advisable to follow the treatment regimen advised by your doctor.

Risk factors

  • Other Comorbidities like Cardiovascular abnormalities, diabetes, chronic kidney disease, hyperlipidemia.
  • Genetics-family history.
  • Smoking
  • Stressful job

Bottomline: Don’t play with your heart. Follow your doctor’s treatment and be a good, adherent patient.

Source: Dale Carnegie (2010). “How to Stop Worrying and Start Living”, p.187, Simon and Schuster

Medication therapy management (MTM)


How many times a pharmacist interventions prevents a major drug-drug or drug food interactions? I wonder if there were no pharmacists, we would have had some many casualties related to these adverse drug reactions. According to fda’s article, :

“The Institute of Medicine reported in January of 2000 that from 44,000 to 98,000 deaths occur annually from medical errors.1 Of this total, an estimated 7,000 deaths occur due to ADRs.”

In countries like US, the practice of pharmacy is so much organized and clinical allowing pharmacists to be integral part of healthcare, helping clinicians with preventing duplication of therapy, drug interactions, promoting patient education and adherence. In countries where pharmacy practice is not so much regulated and clinical, the number of deaths due to drug interactions are significantly higher. In a big country like India, where pharmacies are just treated like “commodity stores”, doctors are too busy to even look at patients’ files, poor patients are pretty much on their own. Can you imagine, how these elderly patients deal with 20 different medications from several doctors? Not surprised, I have witnessed issues like duplication, drug interactions and suboptimal treatment with my own mother who lives in India. I have to intervene periodically so my mom can live longer. Because systems are not integrated, absence of electronic health records and reporting, there is not much data available indicating casualties due to ADRs in India.

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Source: Getty images

If a patient who suffers from conditions diabetes , hypertension, hyperlipidemia finds out that he/she is diagnosed with cancer, then guess what, the person can be completely devastated. And complicate that with the age factor. How does this patient manage his/her medications? How does he/she coordinate with different doctors? How does she make sure that the different medications do not interact with each other? How can she stay adherent to all of her medications? Patients like these need help with managing their medications. So please consult your pharmacist and ask for a comprehensive medication review.

Even third-parties have realized how important it is to help their members with their medications to prevent hospitalizations, ER visits and deaths. That’s why, they reimburse pharmacists for MTM services to save themselves millions and billions!


Medication adherence and health care costs


As per the article by Aurel O Luga and Maura J McGuire: “Between $100 and $300 billion of avoidable health care costs have been attributed to nonadherence in the US annually, representing 3% to 10% of total US health care costs.7,38While there is substantial information relating nonadherence to poor patient outcomes, relatively few high quality studies report the impact on costs. The cost of nonadherence is generally determined by using administrative data to evaluate health care costs in populations of patients who are adherent compared to costs of populations of patients who are nonadherent. Systematic reviews of adherence note that differences in design, cost definitions, and included diagnosis (International Classification of Diseases [ICD]-9) groups, have varying levels of attributable-cost and make comparison of outcomes challenging. Over the last decade, the impact of adherence has been evaluated in association with numerous illnesses, including cardiovascular, pulmonary, gastrointestinal, metabolic, infectious, and psychiatric diseases. Representative findings are presented in our review, including summaries of systematic reviews when available.”

Source: National Cancer Institute/ Unsplash

Just by taking your medications regularly on schedule properly prevents exacerbations and hospitalizations. There are a lot of creative ways that you can improve your adherence: setting up alarms, using some handy apps, use of pill boxes, use of auto refills, etc.

Bottomline: Talk to your pharmacist today and see how he/she can help your live longer and healthier.