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One hitch shop

(Reprinted with permission from America’s Pharmacist, March 2015)

Topeka Pharmacy has been serving the Topeka, Ind., community since 1988. Located halfway between South Bend and Ft. Wayne, in the northeastern part of the state, Topeka’s population of 1,160 is 60 percent Amish and Topeka Pharmacy takes steps to be culturally sensitive yet proactive in promoting good health in this segment of their patient base, as it does with all of its customers.

In this issue, America’s Pharmacist spoke with owner Tom Miller, RPh, about the opportunities and challenges involved in running a typical small-town pharmacy.

What led you to a career in independent community pharmacy?

My father was a coal miner in West Virginia. His grandfather owned the local pharmacy but his sons didn’t follow that track. My dad knew there was no future in coal, so he steered me to pharmacy. (Miller is a graduate of the Butler University College of Pharmacy.)

My family moved to northern Indiana and he took me to the local pharmacy when I was 14. I started working there and never left. I met my lifelong mentor. His family had a store and they survived the Great Depression. He was an excellent retailer.

One of my first jobs was to suspend cases of boxes of facial tissues with rope to create more room in the back. In those days we used to wrap up the boxes of sanitary pads in green paper so women would carry them out. I also used to work the cash register. That was in Goshen, 20 miles away from Topeka.

What makes your pharmacy stand out from the competition?

I would say personal service, although that doesn’t differentiate us from other NCPA member pharmacies. We know everybody and what they need and we do our best to take care of them. It’s a culture of community. We all help each other.

What kind of challenges does your geographic area present for providing good health care and how do you overcome them?

Sixty percent of the population is Amish. Convenience and speed are key for them. For many needs, such as having prescriptions filled, they have to hire a driver, which is a big decision for them to make. That’s expensive, even if five or six families pool resources. If they come to Topeka we try to make it a “one hitch stop.” They can hitch their buggy in town and get everything they need – such as groceries and hardware. That’s a challenge and an opportunity.

It’s a challenge because we face competition from mall shopping and hired drivers taking them there. Another challenge is that the Amish put off seeking what most people consider formal medical care and taking prescription drugs. They may use local people referred to as “chiropractors” to manipulate their body. They readily accept these chiropractors [who have little, if any, formal medical training]. We don’t intervene in their culture but we do try to steer them to a doctor when they need to see one. For the most part, they are like any other folks. We try to find ways to fit into that as best we can. They’re not big on immunizations. Some of the “chiropractors” advise against immunizations. Working to get the immunization rates up among the Amish has been a cause for us. Closer to home, they can get immunizations at a monthly clinic run by the county. If the kids don’t get their immunization during an annual wellness visit, they may not get them at all. A few years ago a child died from tetanus due to not getting a tetanus shot.

They can come in here and get any shot they need without an appointment. They do have to pay for it. If they pay cash, I give them a $5 gift card as a discount.

What attracts people to your pharmacy?

When people have to make a choice of where they shop, they still have to make a decision to go to the drug store.

They are going there for a reason. Are they pulling the buggy rein or steering wheel to the right or the left – to come here or to go somewhere else? We get them to come here because we know who they are and we’ll take care of them and get them in and out quickly.

That’s what these small towns are all about. Many people in this country are served that way every day. We’ve hired a dietician. Amish diabetes may or may not be higher than in other populations, but the diet lends itself to diabetes – high carbohydrates with foods such as beef, potatoes, and cookies. We’ve had some good results with people. We can move their A1C in a positive direction without feeling like they are in jail from a dietary sense. These patients can reduce or drop their meds and improve their health. Word gets out about that in terms of spreading awareness in the community. We also carry a line of therapeutic shoes and operate weight loss programs as well.

We have an office for consultation on site. Our dietician will go to house visits and present the facts and illustrate how minor diet modifications can make a dent in the health. These folks pay their own health care bill, like the national trend. Since they’re paying their own insurance (Amish Aid) these preventative steps can reduce their costs in terms of diabetes supplies. That keeps people in the community and that’s what we’re after. The local hospital is a critical access hospital so we get additional revenue. We are in an underserved community.

How have “preferred pharmacy” drug plans impacted you?

We try to develop every employee to utilize his or her individual strength. When we saw this [preferred pharmacy trend] coming, we thought it would be good to bring in an office manager who works with patients to navigate the Medicare Plan Finder site to find the best plan for their prescription needs and understand how plan choices affect where they can fill prescriptions. We’re not selling anything or promoting a particular plan. But she helps people plug in their drugs and look at the out-of-pocket costs, their income, and so forth. We’ve gotten some additional business out of it as word spread and others hear how we help them. Choosing a plan can be a real can of worms for people. The office manager actually made a house call and we’ve been able to help a lot of people make a good choice for their needs. A lot of the times we are in the network.

If there is a closed network, the patient may have to pick a CVS or Walmart. That’s where it hurts us. Some folks who live right next to us may have to drive to other towns to get that deal.

For 2015, there seems to be some improvement. For some plans they have opened it up some or have less copay differential – the copay differential is less draconian [to use a non-preferred pharmacy]. If it’s a fair playing field, that’s cool with us.

What services do you provide that the nearby chains, if any, don’t/can’t? In other words, is it impractical for patients for PBMS to direct them to big box stores or mail order and if so, why?

We need to make payers and prescribers understand the fact that what we do lowers costs in the system. The Amish count on us for health care information because they don’t have scientific backgrounds or schooling past the eighth grade. They are not going to get that explanation anywhere else. They’re real smart, so you just translate the technical info into something they can understand. It’s the same with adherence. We help to get them to understand from a practical standpoint why it is important to take medication as prescribed. We can relate to the people in our community. And they get it.

We have a florist, provide immunizations, and offer a complete durable medical equipment line (not oxygen); anything people can carry out – such as wheelchairs and braces. We provide home delivery in tough weather or with sick children staying home. We sell over-the-counter products, including Amish remedies.

Our full-service soda fountain, Crossroads Café, operates from 5:30 a.m.-4 p.m. It is full-service for lunch and dinner and seats 50. We’re the center of town for the Amish.

Our pharmacy strives for quick service, but if they have to wait, we give them a “Tommy Buck.” The currency has [Miller’s] picture and they can be redeemed at the café for a cup of coffee or something. It takes the pressure off the wait, and maybe they buy something else. Kids now will ask their parents to get them a Tommy Buck. We also offer copies, faxes, and watch battery replacement.

We furnish goods that cater to our young adult (and young at heart) female non-Amish customers, such as jewelry, scarves, personalized gift baskets, and cards (Papyrus high-end cards). We also have the normal gift shop items (such as puzzles) and part of it is a fabric store – zippers, buttons, anything you need to sew your own stuff.

Can you describe the layout of the business?

Our store is 5,000 square feet on two stories. About two-thirds of the space is the pharmacy/drug store and the rest is soda fountain, dietician office, and fabric shop. The florist has a workspace upstairs.

We have four technicians. I am usually the only pharmacist working. We recently hired another pharmacist, Hannah Smith, who just graduated from Purdue.

With medication therapy management, some of the other nearby pharmacies aren’t offering it, so my wife Morag [also a pharmacist] picks up some, and Hannah will also pick some up.

It’s all a package and we want to present that to the physician. Most of our patients are within a 20-mile radius. You want to get your services and your everyday life needs near your home. At the end of the day they can count on us to take care of them at a higher level. We are transitioning from selling pills to being a service provider on a higher level, and we’re trying to live up to that.

Describe a recent, rewarding experience with a patient.

It’s so rewarding you don’t want to quit. Every day people call us to say thanks. One day a working class father who works near South Bend called. His son had pediatric cancer and was just discharged from the Indiana University Cancer Center. The chain priced the anti-nausea drug that his son needed at $100. I offered to sell it to him for $50. Once he came to the pharmacy, our staff found a manufacturer’s copay assistance card. The card worked and it was actually $10. We had to contact the prescriber to request a change to the prescription because it turned out the card wouldn’t cover 10 pills, but it would cover it for 30 pills.

The patient couldn’t believe the service we provided. He said, “Thank you, thank you, thank you.”

The other day we helped a gentleman who couldn’t speak because of his cancer. I transferred his oral medicines to liquid and for the first time in weeks he was pain-free. He had his wife call to say we changed his life.

I enjoy the autonomy of owning my pharmacy, I don’t have to justify to some home office that we spent this time helping patients.

How are you involved in your community?

I’ve been on the Farmers State Bank Board for 12 years and on the Parkview Hospital Board for nine years. Likewise, our pharmacy staff is active, particularly with the Topeka Area Chamber of Commerce, through which we put together the 4th of July celebration, the Halloween Costume Contest and Trick-or-Treating, the Easter Egg Hunt, and Christmas in Topeka. We also support local sports teams, the Clothes and Food Bank, the Community Clinic for genetic diseases, Habitat for Humanity, the Crisis Intervention Center, Parkview Hospice, and many more local needs.