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Alto Pharmacy Technician

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Blog | Alto Pharmacy

Why We Prioritize Diversity at Alto

The Alto team has been growing quickly, doubling in the last 6 months, and we are thinking a lot about the importance of diversity to building a world-class company. We are putting a lot of time and energy into making sure we build a diverse team and an inclusive culture, and one of the foundational discussions we’ve had is why diversity matters to us. Aside from the fundamental ethical reasons, having a diverse team is particularly important for us as a healthcare company because it allows us to to empathize with our patients, innovate on our product, and hire the best teammates who share our values.

I wrote an internal post codifying how we prioritize diversity, which we presented at an all-hands meeting, and subsequently in every new hire’s onboarding.

I’m sharing this publicly in hopes that it can help frame how other companies discuss the business case for diversity.

Most of any success I’ve had comes down to luck. My family prioritized education and had money to spend on it. I went to an elite prep school, then MIT, then had my first ever job at Facebook. Each step led to the next, with a lot of help along the way. In my time in Silicon Valley, I’ve seen the limits of my well-off, millennial, straight, white, male perspective. I’ve seen the ways that my type of privilege leads to the proliferation of companies building photo sharing apps and other tools that make life easier for the 1%. The massive changes in technology in the last decade have dramatically increased my quality of life, but those who don’t share my privilege have not seen nearly the benefit. Healthcare is clearly broken and hasn’t seen many improvements from improving technology, and many of those most affected by bad healthcare are also the most underserved by the tech industry. We founded Alto to use our backgrounds in tech and our skill sets to try to give some of the benefits of technology to those underserved by the current state of the healthcare industry.

I can have a hard time understanding the thoughts and feelings of our diverse patient base, given my life story and the fact that I’ve never had prescriptions. In the early days of Alto, we primarily dispensed birth control. We thought it was a good beachhead market of young, tech-savvy users, with a long lifetime of monthly refills. We discovered very quickly that birth control has a lot of different brands, some much more expensive than the generic equivalents. I assumed everyone would want the cheaper form, given that they have chemically identical active ingredients. Fortunately, though, some of our earliest teammates were women, and they helped me understand that when dealing with hormones, small differences can really affect how you feel. We then asked our patients about side effects they’d encountered switching to generics and found out how common these issues really were, and how frustrating it could be when the pharmacy tried to switch them to a generic. Now, we make sure to stock every brand of birth control.

In trying to empathize with our patients and my teammates here at Alto, I have seen firsthand the benefits of a diversity of backgrounds and perspectives. We realize that we are a company founded by millennial white males from relatively privileged backgrounds. This makes it even more pressing that we focus our energy on building a diverse team and inclusive culture.

Diversity means many different things to different people, so I think it’s important to define exactly what we mean here. What we’re really after is diversity of thought and skills applied towards a singular mission with unifying values. It’s not always easy to know whether someone has a different way of thinking about the world, so we often use proxies to accomplish this. By attempting to build a team with a broad representation of ability, age, education, gender, race, ethnicity, religion, sexual orientation, socio-economic status, and personality type, we can hopefully build a team that also brings a diversity of thought and experiences.

As a pharmacy, we have one of the most diverse user bases of any product. Almost everyone uses the pharmacy at some point in their life, and so the population of people that we serve is just as diverse as the entire population. We serve patients of every age, race, religion, gender, sexual orientation, ability, and socio-economic status. Having a diverse team allows us to understand and empathize with the people Alto serves. We are building the best pharmacy for everybody, everywhere.

One of our core values is “Patients come first,” and in order to truly embody that value, it is imperative that we have a diverse team. Whether we are designing a new feature to improve our fertility onboarding flow, or talking through a complex prior authorization with an elderly medicare patient who knows English only as a second language, having a diverse team helps us to put ourselves in our patients’ shoes and empathize with their challenges.

As a healthcare company, we are often interacting with patients when they are at their most vulnerable.

We have a responsibility to our patients, and the best way to serve them is to be sensitive to their needs and experiences.

Real innovation happens when you combine people from diverse backgrounds, with different skill sets, to solve a hard problem together. Research has shown over and over the positive effect of diversity on innovation (here, here), and diversity played a key role in many of the greatest inventions of all time. The transistor, a critical building block of the modern computer, was invented at Bell Labs in the 1940s, by a diverse group of scientists and engineers. According to Walter Isaacson,

“The lesson of Bell Labs is that most feats of sustained innovation cannot and do not occur in an iconic garage or the workshop of an ingenious inventor. They occur when people of diverse talents and mind-sets and expertise are brought together.”

Fixing the broken pharmacy industry is an extremely difficult challenge, and we will need a broad range of people, with different ways of thinking, to help solve it. An engineer can quickly write code to automate a tedious task that a pharmacist has to do everyday, like looking up patients to reach out to those who may want a consultation. A pharmacy technician can easily help a designer figure out what the right packaging looks like for fertility ancillary items. By building a team where people with different backgrounds, skill sets, and ways of thinking collaborate daily, eat lunch with each other, and form relationships, we enable more of these interactions, where teammates help solve each other’s problems from different perspectives.

We have hired many of the best people from the tech and healthcare industries, from many different backgrounds. We want to keep doing that.

Most A-players who share our values do not want to work on a team as the only member of a small minority. Neither do they want to work on a team of only people like themselves.

By recruiting a world-class, diverse team, we are in turn enabling ourselves to recruit more world-class, diverse people. It has a compounding effect.

Many of the most talented people who share our company values of empathy, humility, and putting patients first also enjoy working with teammates with different backgrounds and experiences. We enjoy learning from each other and being open minded, and believe that we learn things from each other that actually make us better at our jobs. We feel that a diverse team makes us happier and more productive, and that the best people who share our values feel this way too.

We are all working at Alto because we care about helping people and care about making the world a better place. It is well-known the tech industry has a massive problem with under-representation. Women are under-represented by a factor of 4, and Black and Latino minorities are under-represented by a factor of 2. Women leave tech at more than twice the rate men do, and women are under-represented in leadership positions in tech by a factor of 10.

A study by the Kapor Institute earlier this year found that the primary reason women and under-represented minorities leave their jobs was due to unfairness in the workplace. At Alto, we value fairness and equality as important moral foundations, and work to promote those values in the workplace. We find it sickening to read over and over again about sexual harassment, stereotyping, and unfair treatment in the tech industry, and we want to do something about it. By actively committing to diversity and inclusion at Alto, we hope to do our small part in helping to change the industry for the better.

This post is all about the “why” when thinking about diversity at Alto, and in the future we will be sharing more about what we are actually doing to make sure that we have a diverse team and inclusive culture. We’ve put a lot of work into diversity and inclusion so far, and made some great progress, but we understand there is always more we can do and this is a challenge that will never be “done.” This post is intended only to lay the foundation for taking initiative to improve diversity here at Alto. Without actual changes this is all just talk.

As a mission-driven healthcare company, there are clearly many important reasons why we care about diversity. It helps us empathize with our patients, innovate on our product, hire the best teammates, and change the tech industry for the better. We are growing quickly, so now is the time to double down on our commitment to having a diverse team. It is not something that happens on its own, and will take a lot of work from all of us to foster the inclusive environment in which a diverse team thrives, but we wholeheartedly believe it will be worth it.

The following are the most common reasons for a high copay.

Deciphering Your Copay — What Your Pharmacy Isn’t Telling You

You see your doctor and he or she writes you a new prescription, sending it electronically to your pharmacy of choice. You then receive a call from your pharmacy and the copay is much higher than you anticipated.

Your jaw drops. You find yourself thinking that something must be wrong with this calculation. How did your doctor think you could afford this drug?… Did the pharmacy apply your insurance correctly?… Is this for a whole year’s worth of medication?

If you find yourself in this situation, you are not alone.

There isn’t one simple answer to this question, but hopefully this article will help you understand the potential causes of a high copay and recognize which one might apply to you. The following are the most common reasons for a high copay:

If you notice your prescription drug costs escalate at the beginning of a new year, your deductible is the most likely culprit. With a deductible, patients will pay the majority of the cost of their medications out of pocket until a certain dollar amount has been reached. This amount varies significantly by plan and can range anywhere from the low hundreds to thousands. Once you hit this set amount, your typical copays will return and remain until the start of the next calendar year.

Copayment or drug coverage tiers are a way that insurance companies categorize drugs, and those from higher tiers will most likely cost you more than those from a lower tier. For instance, a brand name drug in Tier 3 will cost you more out of pocket than a generic alternative in Tier 1. Speciality drugs, or those prescribed as treatment for rare or serious medical conditions are commonly at the highest tier, and therefore, are also the most expensive. It is important to note that not all prescription insurance plans utilize tiers, and tiers differ immensely across various plans.

3. The drug requires a Prior Authorization

Oftentimes, insurance companies will reject claims for specialty, brand, or expensive medications without a Prior Authorization in place. A Prior Authorization, or PA, is an appeal process that, if accepted, will result in your Insurance covering a portion of your prescription costs. A PA may require your doctor to submit prerequisite therapy information and diagnosis, and ultimately, justify the reason he or she is requesting this treatment for you.

The important thing to note about PAs is that many drugs that require PAs are also more costly and specialized to begin with, which may affect your out of pocket cost even after it is approved by your insurance.

A formulary is a list of drugs which are covered in some part by your Insurance plan. Each plan has a unique formulary, which you can locate online or by calling your plan. If a drug is not on your “open” formulary, you may have the option of submitting a PA; however, if you have a “closed” formulary, a PA will not be approved. Your pharmacy will be able to inform you on your options and if you have an “open” or “closed” formulary. One thing to keep in mind is that formularies may change without warning, and a medication you are currently taking may be fully covered ($0 copay) one day and not covered, or covered with a copay the next.

We have seen this occur many times with birth control medication, for example, where a patient has been taking one brand for months with $0 copay, and all of a sudden she is subject to a $25 copay for the same medication. In this instance, the formulary has changed, and her Insurance plan is now requesting she takes a different brand, or generic equivalent of birth control medication.

5. You are in the “donut hole” (Medicare Part D only)

The “donut hole” or coverage gap, is specific to Medicare Part D participants, and means there is a temporary limit on what your plan will cover. The gap begins after you and your plan have spent a certain amount towards covered medication for the calendar year. For instance, this number in 2017 is $3,700. Once you are in the coverage gap, you could pay up to 40% of the plan’s cost for covered brand name drugs, and will pay 51% of the cost for generic drugs. These percentages may change year after year, and your costs incurred will add up over time to get you out of the coverage gap. You can find more information and specific examples of the coverage gap on the Medicare website.

Fortunately, you may have a couple options to cut your costs. If your doctor prescribed a brand name medication and there’s an alternative available, you may have the option of filling this instead. If the doctor requires that specific medication, talk to him or her about why, or ask your pharmacist to follow up for a new prescription. If an equivalent generic does not exist, there still may be a comparable substitute, which you should discuss with your doctor or pharmacist.

In the case of a Prior Authorization, your doctor can submit documentation to your insurance company explaining why this specific treatment is necessary. At Alto (formerly ScriptDash Pharmacy), we initiate this process with your doctor and track its progress, as well as notify you along the way.

A third way to lower your out of pocket costs, perhaps significantly, is to apply a manufacturer’s copay savings card. These savings cards are typically found with more expensive brand name medications and are accepted for the most part after your commercial insurance has paid for a portion of the medication. Lo Loestrin Fe, for instance, has a savings card that will bring down out of pocket expenses to $25 for a 28-day supply, which can be much lower than your initial copay when you only use your insurance. At Alto, we make this process easy on you and will actively search for, and apply, any savings cards for which you are a candidate.

While this isn’t an exhaustive list of everything that could contribute to your copay, it covers the majority of cases we see here at Alto. If you have any questions on what your insurance covers, you can always contact us for help. Alternatively, you can learn more about your insurance coverage by calling the number on the back of your card or by looking up your formulary online. We hope this takes some of the guess work out of deciphering your copay and will help you make more informed healthcare decisions in the future!

The following are the most common reasons for a high copay:

In recent years, EHRs and medical providers started to dispose of the paper prescription pad and began to send some prescriptions electronically from their EHRs. Those that know Alto Pharmacy know that we want all prescriptions to be sent electronically. It’s more efficient for providers and safer for patients.

The Case for E-Prescribing

Did you know that Electronic Health Record Systems (EHRs) have been around since the 1960s? Pretty much as soon as we got computers we realized that they could be used to make healthcare more efficient and more effective. Despite the massive forward leap in adopting EHRs, the tools used for prescribing medication didn’t change for another 50 years.

In recent years, EHRs and medical providers started to dispose of the paper prescription pad and began to send some prescriptions electronically from their EHRs. Those that know Alto Pharmacy know that we want all prescriptions to be sent electronically. It’s more efficient for providers and safer for patients. Whenever we broach this topic with medical providers we often hear them say “It’s illegal to send Schedule Two Narcotics (CIIs) electronically.”

The DEA made EPCS (Electronic Prescribing of Controlled Substances) a legally acceptable option for prescribing in June of 2010. Unfortunately the belief that it’s illegal to e-prescribe CIIs is widespread among medical providers and undoing it requires an awareness campaign. In 2012 the State of New York recognized the benefits of EPCS and passed legislation making it mandatory to E-prescribe all medications as of March 2016. We believe many more states will soon follow.

The Center for Disease Control and Prevention (CDC) has declared prescription drug abuse in the US an epidemic. Nearly 10% of all prescriptions written are pain relievers (opioids), which too frequently lead to patient dependence and abuse. It’s important to remember that seventy-eight Americans die every day from an opioid overdose.

As long as these prescriptions are written on a piece of paper, the pharmacies dispensing the medications can be easily manipulated and the dispensing cannot be easily tracked. Electronic prescribing saves lives by making it harder to commit fraud.

Did you know that the street value of the paper in a prescription printer is over $20,000? Get your hands on one of these printers (or even easier, a paper prescription pad) and you can mint whatever prescriptions you want. As long as you take each prescription to a different pharmacy and always pay cash, it’s hard to get caught. The result of this paper based prescription process and the large volume of CIIs being prescribed in the US is causing epidemic scale drug abuse and nearly 29,000 preventable deaths every year.

Although undocumented, medical errors have recently been estimated as the number-three cause of death in the United States. As an example, today it is far too easy for a pharmacy to accidentally translate a handwritten prescription for Oxycontin (extended release) into Oxycodone (immediate release). Depending on the prescription strength and the patient’s tolerance for opioids this could be a very serious medical error that in some cases may result in death. EPCS significantly reduces the risk of this medical error and saves lives by eliminating room for interpretation.

3) Make Medication Reconciliation Accurate

Reducing medical errors and helping prevent opioid abuse are great reasons to get rid of all paper prescription pads, but there’s another reason that’s not so obvious. When a patient’s prescriptions are sent electronically they can be easily tracked, which means they can also be used in medical reconciliation. Imagine if you had a complete and accurate view of all of your patient’s prescription medications? Imagine if your EHR allowed you to see everything that was prescribed in the last two years and when it was last picked up? Now imagine the power of this information in an emergency inpatient setting. How many lives could be saved?

PDMP is currently enacted in every state except Missouri, and is invaluable in helping pharmacists track controlled substance transactions. PDMP, also known as ‘CURES’ in California, requires pharmacies to report controlled substance dispensing to a searchable database. In California, pharmacies are able to log into CURES and view data on all reported dispensing of controlled substances.

‘Red-flags’ dispensing pharmacies look for:

Multiple controlled substances dispensed under multiple providers.

Large quantities of controlled substances regularly dispensed.

Patients that often don’t use insurance for their controlled substance prescription.

CURES allows dispensing pharmacies to make informed decisions that can curb the abuse of medications. CURES, however, isn’t always checked. Retail chain pharmacies are frequently challenged with an increasing volume of prescriptions with less manpower, and checking the database doesn’t happen at all pharmacies 100% of the time. For this reason we believe tracking the prescriptions through an E-Rx network is a better solution and a more accurate source of truth.

How does a prescription get to the pharmacy from my EHR?

In 2015 Surescripts electronically delivered over 9.7 billion prescriptions and connected over 240 million patients. If your practice is using a moderately popular EHR it’s most likely integrated with the gold standard eRx network, Surescripts. When you select a pharmacy in your EHR and send the prescription, you are using Surescripts to deliver the prescription. When the prescription arrives in the Pharmacy Management System, it indicates that this is a legal prescription sent by a legally authorized medical provider.

What other medical providers support EPCS?

In the 2015 National Progress Report we saw a 667% increase in EPCS from 2014, with over 12.8 million e-prescriptions of controlled substances sent on the Surescripts network.

Looking at this chart it’s pretty clear that EPCS is on the rise and eventually every provider will be e-prescribing. Due to the severity of the issues associated with paper prescriptions, we urge you not to wait. Here you can see a list of all medical providers near you that have enabled EPCS. We ask that you do everything in your power to join them in their efforts to save lives and make healthcare more efficient.

Most major EHRs support EPCS. If you are part of a large hospital system, please contact your Director of Pharmacy and request EPCS access. If you are part of a private clinic you can verify if your system supports EPCS here. If your EHR supports EPCS, simply ask your administrator to enable it. If your EHR is not on the long list of systems that support EPCS please contact their support, requesting a timeline for when they plan to enable it. If it’s not on their radar, they forgot the ‘e’ in EHR. In this case please consider alternative EHR solutions that will ultimately save lives.

When you ask your EHR provider to enable EPCS, they will verify that you are legally authorized to prescribe CIIs by verifying your DEA and NPI numbers. Once verified they may ask for a small fee to enable the licensing for e-prescribing. Notably, systems like Epic do not charge any fees for enabling EPCS.

When prescribing CIIs your EHR will ask you for a temporary key code for every prescription. This is the digital equivalent of the“wet signature” that is required when you write a prescription on paper. This is also known as Two-Factor Authentication (2FA). Other forms of 2FA include the increasingly popular biometric method. You can learn more here. Once you successfully enter your temporary key code or satisfy the 2FA requirement in some other way, the EHR will send the CII prescription to the pharmacy of your choice.

In the process of verifying you as a medical provider that can lawfully prescribe schedule II narcotics, your EHR will outfit you with a tool that supports Two-Factor Authentication. This will either be a tool you log into on your computer or smartphone, or a device you cary with you. When you log into the tool or press the button on the device, it will give you a temporary code that is unique to you. You simply enter that sequence of numbers into your EHR and the prescription is ‘signed’ and ready to send electronically.

Once verified by your EHR, you’re all set. You can now E-Prescribe Schedule II Narcotics. This is a very big deal! This change in prescribing means fewer cases of opioid abuse and dependence, fewer medical errors, and a much more efficient and convenient process for you and your patients. You are now leading the industry in a new way of administering healthcare, and we welcome you as a proud partner of Alto Pharmacy.

Rapidly Growing San Francisco-based Startup Teams Up with Specialty Pharmaceuticals Veteran to Build the Modern Pharmacy

ScriptDash Appoints Dr. Mike Cunningham to Board of Advisors

SAN FRANCISCO, CA; November 3rd, 2016 — ScriptDash Pharmacy, a health-tech startup focused on building the modern pharmacy, announced today that Dr. Mike Cunningham has joined the one year old startup’s Board of Advisors.

Dr. Cunningham was most recently Vice President and General Manager, GPO Services, for McKesson Specialty Health (MSH), a business unit of the McKesson Corporation. There, he oversaw day-to-day business operations and long-term strategic planning for MSH’s group purchasing organizations, Onmark and Unity. Dr. Cunningham has deep expertise in healthcare having spent more than 30 years structuring, developing, and implementing relationships with pharmaceutical companies on behalf of practices and pharmacies.

“Dr. Cunningham has devoted his entire career to oncology and has accomplished remarkable feats in the industry. His reputation precedes him. We are excited to work with Mike as we build the pharmacy of tomorrow together.” — Vlad Blumen, Co-Founder

At ScriptDash, Dr. Cunningham will be a key advisor and partner in securing access to new, limited distribution specialty medications.

“I’ve been very impressed with the senior management team and their desire to significantly improve the patient pharmacy experience through modernization” — Dr. Mike Cunningham

ScriptDash Pharmacy is a year-old software startup based in the historic Dogpatch neighborhood of San Francisco. ScriptDash is disrupting the CVS and Walgreens dominated pharmacy industry of big box retail pharmacy chains by offering free same-day delivery of prescriptions.

Everyone knows the pharmacy plays an important role in the healthcare system. Every one of us, in our lifetime, will need to see a doctor and inevitably at some point we will also need prescription medication.

"How Do You Make Money?"

Everyone knows the pharmacy plays an important role in the healthcare system. Every one of us, in our lifetime, will need to see a doctor and inevitably at some point we will also need prescription medication. Today, when we need that medication, most of us simply tell the doctor to send it to the local pharmacy that serves more as a convenience store than a healthcare source.

When we speak to medical providers about our pharmacy (one that is not a convenience store and only focuses on offering the highest-quality patient care), the doctors always scratch their head and asks, “how do you guys make any money?” As much as we all interact with and rely on a pharmacy we often don’t understand its business model. “How can they make any money if last time I came in I didn’t pay anything for my prescription medication?”

The pharmacy fills a bottle with the prescribed medication.

The pharmacy bills the patient’s insurance for the medication.

The difference between what the pharmacy paid for the medication and what the insurance company reimbursed for the medication is profit.

Even though you had a zero dollar copay your insurance typically reimbursed the pharmacy around $60 for that prescription and they made (typically) about $12 in gross profit margin. Imagine now that you are a patient that takes 3 prescriptions per month. That’s $180 in recurring monthly revenue that the pharmacy gets every time you pick up your medication.

“I thought they made all of their money on the other stuff they sell.”

Even though the actual pharmacy portion often takes up the smallest part of a retail store like a Walgreens, it typically generates two-thirds of the store’s total revenue. Those medications make a lot of money for the pharmacy. In fact, the US consumes almost $1B per day of prescription medication (12.9M daily prescriptions).

“If a pharmacy makes so much money, why is it so bad? Why is it almost universally disliked and a huge source of friction for medical providers, patients and even insurance companies?”

Well… large-chain pharmacies have realized that they don’t have to be good. This is because they have a clever way of acquiring customers which doesn’t require them to compete on quality.

“What is this clever way of acquiring customers?”

They’re on every corner! AND they sell everything we might need. Need household goods? A high-calorie snack? A cold soda? Lightbulbs?… Great! They can help us with that. As long as we go there for our convenience goods, they know that when a doctor asks, “where do I send this high-priced prescription?” patients are likely to say, send it to that convenience store right by my house where I get all of my last-minute needs taken care of (even though I really loathe dealing with their pharmacy). Where else are we going to go? Aren’t all pharmacies the same?

There are roughly 120 pharmacies in the city of San Francisco. A city that only houses 800,000 people. Each pharmacy is about 6,000 square feet and is often positioned on the most high-priced and high-trafficked real estate in the city.

We believe that you only need one pharmacy to service the entire Bay Area. The medication should come to the patient (not the other way around) and that pharmacy should compete on quality of care (outcomes). We call it The Modern Pharmacy. In order to improve patient outcomes The Modern Pharmacy should work closely with doctors, insurance companies and patients to provide a frictionless healthcare experience. No need to build hundreds of storefronts or lure patients in with convenience-goods. Just focusing on being the best pharmacy allows us to work with doctors to improve patient outcomes and advance healthcare into the modern era, profitably.

Blog

Why We Prioritize Diversity at Alto

Deciphering Your Copay — What Your Pharmacy Isn’t Telling You

The Case for E-Prescribing

ScriptDash Appoints Dr. Mike Cunningham to Board of Advisors

"How Do You Make Money?"

Switch to a better pharmacy.