Thursday, January 29, 2009

Just Random Thoughts

I really expected a lot more bitching about the Albuterol HFA inhalers (I mean how they work, not the price -- that, they do complain about). There have been a couple of hard-core customers who snarl that they 'don't work' but for the most part people seem to have taken them in stride (so far, anyway).

I wish doctors wouldn't write scripts for things like Zyprexa and Cymbalta and Abilify without having some idea of what they cost, and whether the patient's insurance is likely to cover it. Lately I've dealt with some pretty scary customers who really need the stuff but are in no position to pay for it. I'm the bearer of that bad news.

I wish doctors & nurses wouldn't tell patients that I will 'waive' the copay. No. I might get the patient started on the med and have them come back and pay tomorrow, or I might figure out some other way to deal with it. Don't make business decisions for me and promise patients something just to get yourself off the hook.

Another Dear Doctor: When discharging some elderly, non-English speaking person from the hospital, don't give them a script for an exotic wound-dressing product without giving them ANY idea of where to get it.
Even I never heard of it, so think of the trouble THEY'RE going to have!

And lastly, please deliver me from the hordes of customers that suddenly materialize 10 minutes before closing with stacks of prescriptions and insurance cards that are TERMINATED. What IS it about closing time that brings that on???

Monday, January 26, 2009

My Everyman's Guide to the Basics of Hospital vs. Retail Pharmacy

I thought it would put in my 2 cents on the comparisons of working hospital vs. retail pharmacy, as I have done both, each for a significant period of time. Let me say first, I am not a high-powered 'clinical pharmacist' -- my first years in hospital were pretty much in the basement processing orders and doing a lot of troubleshooting by phone. As the job evolved and I changed employers, I also spent time as a decentralized pharmacist, responsible for an area of the hospital where I would process orders on the nursing unit, resolve any issues with those orders, do MAR reviews, carry a pager so the nurses/ward clerks could contact me, and do some aminoglycoside and vancomycin dosing and be available for any other problems that came up. My rundown, on a personal level, of hospital vs. retail:

Using Your Knowledge --
Whether you're in hospital or retail, it's what you make it. Hospital has just as many routine and repetitive tasks as retail, and hospital pharmacists deal with an array of drugs (especially injectables) that retail pharmacists never see. But in hospital you don't see a lot of the drugs that are widely used in the community (Tri-Sprintec? Propecia? What the heck is that?) Any 'good' pharmacist will be on their game wherever they are practicing. When I worked hospital (before retail) I always envied my retail colleagues as seeming to possess a lot of practical, nuts-and-bolts knowledge that I didn't because they dealt more directly with the consumer of the medication and knew far more about down 'n dirty cost issues.

But for some, these are the very reasons they want out of retail. Either way, I've seen supremely talented retail pharmacists who have a knack for dealing with the public, and I've seen the same in hospital who love what they're doing. One environment isn't any more prestigious than the other, they're just focused differently. In hospital you may get into one very specialized area, get good at it and pretty much 'forget' everything else - in retail, you've got the chance to maintain a little broader knowledge base. It all depends on the job.

Who You Work With --
In retail, you're in contact with the public and generally work with a small group of people behind the counter. In a hospital of any size, you're likely working with a larger pharmacy staff and instead of the public, you have a lot of contact with other health professionals; physicians, yes, but far more often with nursing staff (RN or LPN), ward clerks ("health unit coordinators") and occasionally a dietician or respiratory therapist. These individuals can vary widely in their experience and general competence. You've got to be able to adapt and work and play well with others. You won't always get your way. There are significant turf wars between these groups and you have to be comfortable asserting yourself without being an a-hole (a mistake I've seen many a pharmacist make.)

Physician contact can be very satisfying. Some will be receptive and some won't, and you have to be comfortable enough with your abilities to know how to approach them. If you're in a teaching hospital the med students, interns and residents present lots of opportunities for education, although I often found them to be so bombarded with learning how to 'diagnose' that the prescribing part just wasn't on the radar yet and they looked at me a little wild-eyed when I tried to explain how to write an order. (!)

I worked with some purely 'clinical' pharmacists who complained that all they did was chase after doctors to correct things they were doing --- in a few months, a new crop would come through and they had to start all over again. Some were burned out by it.

Nurses are the key, though. You've got to be nice to the nurses. If they learn to like you and trust you they will ask a ton of questions and you will learn a lot from that too.

The Boss ---
You may have a manager in retail who's always looking over your shoulder, or you may have a manager who leaves you alone. In retail, I kind of enjoy the autonomy. When I'm with a patient it's just me and them -- I'm the pharmacist and they're not. Of course some customers respect you and some don't, but you're calling the shots. In hospital, you'll often have the 'multiple boss' situation. You might have an area supervisor, several middle managers, a clinical supervisor and a director of pharmacy. This can present the obvious difficulties (see any "Dilbert" comic strip). You have these hierarchies in retail too, but you generally don't see those people every day.

Patient Contact --
This depends a lot on what job responsibilities you have in hospital. Generally, patient contact is less than retail of course. If your hospital requires pharmacist discharge counseling you'll have patient contact. For in-patients, you are generally not wandering in and out of rooms chatting with people and you'll probably be too busy anyway. There can certainly be opportunites for patient contact when medication questions arise, but generally it's less.

Routine Work --
Every job has its routine duties, hospital as much as retail. I couldn't begin to count the number of IV solutions, TPNs, crash carts and unit dose carts I checked over my hospital days. Unit dosing in hospitals is very labor intensive. When I left hospital there was talk of some 'checking' duties being taken over by certified techs, but I don't know if that is a reality or if it should be.

Pharmacists will always be required to perform many of these duties -- advanced degree or not.
Retail pharmacists should not feel any inferiority complexes about using their 'clinical' skills. Again, it's what you want to put into it. In fact, retail pharmacists need to be more diligent in some ways -- when a hospital patient crashes, there's a whole army of people there to respond. When your retail customer crashes at home at midnight due to a drug interaction they're in much more danger.

Pay --
If you go from retail to hospital you will almost certainly take a pay cut, the extent of which can vary based on where you live and the job climate.

The Hours --
In hospital, 24/7, weekends, holidays. Of course this goes for some retail outlets too. I never had to work graveyard shift, but I worked a lot of 2-10pm and 3-11pm's. I never really liked evenings and if you've got family responsibilities it's a hell of a long day. Evening shift was always understaffed for the amount of work we had, and often times I felt dumped on by the day shift. However, it can also work to your advantage if you're sharing child-care responsibilites or just aren't a morning person. Flexible hours and scheduling can be nice, no question. It may be more of a factor at different times in your life, ie. if you're married/single/children or no children, etc.

The Working Conditions --
Hospitals can be depressing. Reading the charts of sick people can be depressing. You do need to have some detachment and that was sometimes hard. I avoided being scheduled in the ICU (and especially, the pediatric ICU) because I felt uncomfortable and untrained for that. If your hospital employer is going to put you in those types of areas and require you to attend 'Code Blues' for example, insist that you be thoroughly trained and feel comfortable doing it. Again, there are some pharmacists who will gladly take it on and that's fine too. Maybe you have completed a specialized residency. I took it very seriously, and it bothered me to observe pharmacists with an over-blown sense of their own importance who walked into some of these areas with little background.

The 'Little' Things --
When I started in retail, I was actually excited by some little things, like not being charged for parking! To pull into a surface lot and walk into the front door was well, damn nice. In hospital I had to allow an extra 10-15 minutes to circle the parking ramp for a spot and get myself into the department. Also, I cannot overstate the delight of being at work and seeing DAYLIGHT out the window!! I honestly felt like I was back in the land of the living, out in the world!

In comparing hospital vs. retail, I don't mean to favor one over the other. I enjoyed hospital while I did it and learned a lot -- it just ran its course for me. I had a chance to work fewer evenings and weekends and I took it, and I also got tired of the top-heavy bureaucracy of hospital life. My transition to retail was made easier by working with some very knowledgable technicians who really helped me till I got the hang of things. If I had gone to a retail store with high turnover and inexperience, it would have been much harder.

Friday, January 16, 2009

Mail Order Pharmacy -- We're Here for You -- Not.

I get a sense of satisfaction when a patient decides they are fed up with mail order and decide to have their prescriptions transferred back to an actual face-to-face pharmacy. I was reminded of why today when I had to call a mail-order pharmacy to transfer one simple prescription. This company is called "NextRx", apparently run by Wellpoint.

Of course, the 1-800 number on the patient's bottle is just there to taunt us. I navigated a lengthy menu to get to a customer service agent. When told I needed a transfer, they put me on hold, then came back and told me they were transferring me to Mason, Ohio, where the pharmacists are (I guess.) Again, another lengthy menu. I finally get a person who takes the information I need (verifies patient, date of birth, my name etc etc -- I'm getting giddy because I'm almost there !!) then tells me they are transferring me to a pharmacist. I waited on hold about 10 minutes. Now, by this time, I'd like to hang up but I am already vested in this process -- you know the feeling ---- I've got THIS far, maybe it will just be a minute longer. And I plan to bitch to someone, just to make myself feel better. But the pharmacy got busy, and I'm the sole pharmacist, so I had to hang up.

Now I am really determined to get hold of someone, if only to ask them one question: WHAT THE HELL KIND OF BUSINESS ARE YOU RUNNING ???

I call again, repeat the steps above, tell another person my story and let them know I've been on hold forever. Give the same information again. Get told they are transferring to 'the pharmacist.' I wait on hold and listen to music for at least another 10 minutes and finally give up.

Now, I'll end up calling the patient's doctor myself just to get a new script. I can do that. But this NextRx outfit obviously has a system in place to get a transfer, but I'd like to inform the people at NextRx it ISN'T WORKING. If there is NO chance that someone will take my call within a few minutes, just tell me and stop wasting my time.

I can only imagine the living hell your customers go through if they actually have a question on their medications. Good GOD is all I can say.

Monday, January 12, 2009

Oh, those wacky rejects

When pharmacists process prescriptions we submit an on-line claim to the patient's insurance plan (their very OWN individual plan -- that's why we need that CARD). Anyway, the claim may be rejected for a variety of reasons, many of which are fix-able without too much difficulty and some that will most certainly cause a delay, like "DRUG NOT COVERED." The insurance company's computer will give us some sort of short message which is meant to explain the reason for the reject.

Pharmacists know that sometimes these messages make sense and sometimes they are complete gibberish. Sometimes the reject message has absolutely nothing to do with why the claim is actually being rejected. Either way, a call to the insurance company is needed while the customer waits -- sometimes understandingly, sometimes not.

A recent example; refill for nine Ortho-Evra patches. When used as directed, this is processed as an 84 day supply (one per week for 3 weeks per month). My reject said:

"Plan limitations exceeded. Group LIMIT DAYS 84 per 84 days, 0 LEFT."

The only thought I could come up with was, she gets the first 3 months at retail then has to use mail-order? What does "0 left" mean? We're not dispensing 84 per 84 days..? Call to insurance, on hold awhile --- turns out it's a simple 'refill too soon.' Maybe "Refill too soon, next fill date XX/XX/XXXX" would have been a better message for us to have received.

Then there was the ever popular "Missing/Invalid Cardholder ID/BIN/PCN." All information was entered as on the card. Patient was sure it was current information. We try a few different things. Customer is getting tired of waiting. Technician navigates the insurance company's phone system, finally gets a person. Long story short, it's got nothing to do with the cardholder's ID/BIN/PCN. We're trying to fill a script for Azithromycin 500mg -- 1 tablet a day for 5 days. That's 5 tablets --- his insurance will only pay for 4. I dunno, maybe a reject message like, "Plan limitations exceeded -- max 4 tablets" or something like that might have saved us a lot of time? -- call me crazy.

One of the pharmacy magazines (I forget which) has a feature where people send in illegible prescriptions to see who can figure out what they actually say. Maybe they could do the same with some of these insurance rejects.

Thursday, January 8, 2009

Creating Chaos

Today was chaotic. It was one of those days where people were impatient. It was apparently our fault that they were late for work, or had another appointment, and they seemed surprised that the prescription-filling process didn't consist of merely pulling the next Big Mac off the conveyor. No matter what estimated wait time we gave people, they kept coming back to the counter after a few minutes, wasting the time of staff members who went chasing down their prescription to see how it 'was coming.' It's just insane behavior. SIT DOWN and WAIT for your name to be called.

What really drives me nuts is when someone comes up and declares, "they told me it would be 15 minutes and it's now been 35 minutes." So I get their prescriptions out there, and lo and behold, they're not in such a rush anymore!! They proceed to tie me up at that counter for another 15 minutes by settling in for a long discussion about just plain stupid stuff. Now, I don't mind answering any questions about the prescriptions. But I don't want to listen to long bitch sessions about insurance, or about why the doctor wrote for naproxen when you told him it doesn't work, or why the doctor only gave you 10 ambien (dammit, I wasn't in the room with you, I DON'T KNOW!!). I don't want to stand there while you decide whether or not to actually purchase the prescription you've been waiting impatiently for, and needed so desperately. All I know is you've been chomping at the bit since you handed these prescriptions over, you've rushed me and everyone else like you're our only customer, and now you refuse to let me get on to the next customer who's also been waiting longer than we told them they would (and will probably repeat this scenario.)

People need to understand: if you want me to spend time with YOU, you have to be willing to wait while I do the same for others. Just a little awareness of your surroundings would be super. And 'wait times' -- well, they're just an estimate. Get over it!!!!

Monday, January 5, 2009

Time was on my side

I managed to cobble together a few days off over the holidays and it sure was nice. I especially liked staying up later at night knowing I didn't have to hit the alarm at 6am and get ready to face the onslaught.

It's just nice to feel you've got a little time stretching out in front of you. I read "Scarpetta" by Patricia Cornwell and started "Revolutionary Road." I always like reading the year-end issues of Time and Newsweek. I went to see the new movie "Milk" and rented "Little Miss Sunshine" (again). Got to watch some TV too! -- Discovery Channel "Planet Earth", the always great "Seinfeld" re-runs, the Ron Howard retrospective on TCM and Sci-Fi Channel's reruns of the old Twilight Zone series (love those!). I even got to see a Christmas "musical" live show.

Not as exciting as going to Cancun or Hawaii or Europe, but this year it suited me just fine.
Christmas travel sucked anyway!

And now, going back to work, we shall all observe the Eleventh Commandment: Thou shalt not ask me why thy copay has gone up when thou just handed me a brand new insurance plan.