Saturday, November 3, 2012

Boogie on Down

I love scanning the chain-store ads for new OTC products -- not only because I get asked about them, but because it's always interesting to see what's "NEW!" -- that is, same ingredients in a different form.  One of
my favorite marketing devices is when they take an external product and put it in the form of a 'wipe.'
So we have eye-makeup remover wipes, facial cleansing wipes, bum-cleansing wipes, disinfectant wipes, furniture polish wipes, and so on.   But "Boogie Wipes" really has to be my favorite one so far.   Forget the Kleenex, ladies and gentlemen!!  This is the wave of the future!

Monday, October 8, 2012

Keep it Real !!

We have a regular customer, elderly, always nice, who cares for his elderly wife and seems somewhat overwhelmed most of the time. Shells out big money for a variety of prescriptions.  The other day a prescription for nystatin powder was called in for his wife. We ran through the quantity that was prescribed and it was ridiculously expensive (yeah, nystatin powder -- WTF?)  He shows up to get it, and we jointly decide on a lesser quantity to start with, so it's not so expensive.

I asked him how large an area he was using it on. He said he had a couple of other creams he was using for his wife's pressure sores, and he had been instructed to 'mix' the nystatin powder with those creams.  He seemed a little hazy on the details, and as I say, overwhelmed.  Why would someone instruct this 80-something couple to be mixing creams and powders?  Do we really need to complicate their lives like that?   There are other things they could use --- heck, tell me the proportions and I'll mix it for them (unfortunately not an option today, a Friday afternoon at 5pm, much to my frustration.)

I shake my head at the impracticality of prescriptions sometimes. I think part of 'treating' someone is stopping to think whether they are capable of carrying out the instructions.  Everybody's got good intentions but it is wasted time and MONEY to send people out the door with instructions that are difficult for them to perform or a course of treatment that's unlikely to be completed.  I admire the prescribers who think outside the box and who can come up with something simple as an alternative, even if it's not by-the-book treatment.

Speaking of practicality, I had an encounter with a bunch of prescriptions the other day for a patient who was fresh from an MTM session.  Good intentions all around, but practicality --- zero.   All sorts of medications were added -- vitamins, combinations, other items meant to address some perceived need.
No thought was given to how much they cost, whether they were covered, or how much more complex they made this patient's life.  The meds have never been picked up.   Don't get me wrong, I understand the philosophy behind Medication Therapy Management and I'm not trying to sound grumpy about it.  But this is a total failure unless somebody takes into account whether it's practical.  There's more to it than what looks 'good on paper. '

Sunday, September 9, 2012

Co-Pays and No-Pays

I guess because it's an election year people are thinking about the 'health care' debate and peripherally paying attention, although in their own typical way --- "hearing about" stuff, and rumors, and watching the cable news channel that they agree with most -- without actually doing any hard reading or research.  I'm no expert either, but from my perch as a pharmacist I detect certain trends.  It hit me the other day when I had a customer grumble about his $59 copay for a 3-month supply of 4 prescriptions. It's my feeling that during the time I've been a retail pharmacist, copays have been trending down. Most of the drugs we dispense are generics -- the big expensive brand-name drug with the big copay is becoming less common. Maybe that's why people's expectations are that everything's eventually going to be 'free.' But of course nothing is 'free.'   I don't have any problem with a reasonable co-payment for prescription medications.  I don't think that the $59 tab was unreasonable at all. The future legislation is called the "Affordable Health Care Act", not the "Free Healthcare Act."   People are flabbergasted at how expensive something like, say, Seroquel is;  well, yeah, it's a drug that alters your brain chemistry and which took years of research, testing and know-how to develop and put into a little tablet that you can swallow and fix your 'mood disorder.'  It might even change someone's life? What's the price on that? And yet people can also take a dirt-cheap drug that keeps their blood pressure under control and prevents them from having a heart attack or stroke.  That's pretty significant.  I don't think people get this.
  It's the same old story -- the cheaper something is, the less value it's perceived to have and therefore all the professional services behind it are cheapened too.

People used to treat a doctor's prescription like gold.  They would fold it and put it in a safe place (their wallet) and bring it to the pharmacy almost immediately. Now they are treated like grocery store coupons-- collect 'em, trade 'em, transfer 'em, and (my favorite), lose 'em.  And what they represent also seems to have declined in value, where $59 is apparently outrageous for those multiple 90-day prescriptions.  I guess I just remember a different era..... or something.....

Now on the flip side, I would like to address my workplace.  If you're going to complain that customers don't treat you as a professional, then for God's sake, ACT  PROFESSIONAL.
1.  Wear some decent clothes.  Wear your identification badge like you're supposed to.
2. Stop cooking your lunch in the pharmacy microwave so the entire place reeks.  It smells like a damn          Burger King in here.
3. Stop EATING, snacking and drinking all day in the pharmacy. IT LOOKS TERRIBLE.
4. If someone talks to you from out at the counter, get out there and talk to them. Don't holler across the   room. Respect people's privacy, even if they are oblivious.

Can you tell what's been bugging me this week?

Monday, August 13, 2012

Subject: Miscellaneous

I've got a few things running around my head to vent about.

1. E-scripts.  It's official, I HATE them. I have never seen such a run of errors, ambiguities, lazy and nonsensical stuff coming through on these things.  Yeah, they're great if the prescription is "Amoxicillin 500mg, one TID."  But for anything that requires any degree of thought, forget it.  So we have the situation where doctors are sending us one set of directions because they are pre-loaded into the system, but telling their patients something completely different, because they don't know how to change it. They don't know how to add special directions, like where exactly to apply each of those 3 ointments they just prescribed. So, when it comes time for my little counseling session with the patient (who hasn't listened or has forgotten everything the doctor said),  we're both clueless. I actually had a doctor (attempting to prescribe nystatin cream) select an entry for a multi-ingredient compounded ointment because it 'contained' nystatin, which I guess was good enough for him, and stick the words 'nystatin cream' in the comment section of the prescription entry which was his way of saying...... I don't know what the hell I'm doing.  I mean seriously?

2. I got a big drug order from my wholesaler but was missing some of the paperwork. I call the wholesaler, give them my customer number and all that --- she types it into a computer and says, "I don't show any order sent to that customer," followed by....... total silence.  That was the SUM TOTAL of the amount of 'customer service' that she was prepared to offer me.  God, I hate that.   OK, I guess this stack of totes from your company is just a hallucination, then. Bye.

3.  I get calls at work from drug companies wanting to tell me about some new product.  Why do they insist on doing this?  I really hate to be rude, I know the person on the other end is just doing their job, but I simply cannot stand there and listen to any spiels with the place going crazy around me and customers staring me down.  I've got enough crazy customers wanting to keep me on the phone for twenty minutes because (and this is true) they want to discuss a pharmacy charge on a bank statement from TWO THOUSAND AND TEN. That's 2010. Twenty-frikkin-ten.

There is an article in the current New Yorker magazine by a surgeon named Atul Gawande called "Big Med."
It's very interesting and I recommend it .  This author has written many articles and at least one book that I know of, and I think he's an example of one of the smart people that we should listen to in the whole health care debate ---instead of these idiot politicians, I mean.   I come home after a particularly trying day and I think a lot about how we do things.  One day I'm working in a well-oiled machine with everyone at the top of their game, and the next day it's a different staff who can't even stick a label on straight.  But more on that later.

Monday, July 16, 2012

Health Care Blues

The scenario:  A young woman, a member of a large immigrant population in our city and on state assistance, brings a prescription to the counter. It is from a prescriber who staffs what is commonly known as "urgent care" or "quick clinic" or by many other names -- a walk-in, no-appointment- needed type of area which is intended to address problems that are acute, or can't wait for a regular doctor's appointment.  Her prescription: Differin Gel (its generic form) -- a topical acne medication.  It costs over $200 for a 1- 1/2 ounce tube.  Her out of pocket copayment: Zero.   She collected the medication, picked her smartphone up off the counter, and was on her way.

Now, I know this is a sensitive topic.  I'm not suggesting that immigrant populations, or those on state assistance, don't deserve quality medical care.  Of course they do.  But does this qualify?

This nagged at me in so many ways.  Why is an "urgent care" provider seeing people for acne? (Don't get me wrong, half the stuff coming out of Urgent Care is not urgent).   Do they know that they have selected a $200 medication? Should it be covered under a state plan when many private insurance plans don't, or at least require prior authorization?

The fact that health care legislation is always in the news now makes me more aware of this stuff. I don't pretend to be an expert on all of it, but I can look at the prescription side of things and see a lot of things that don't make sense.  People sound alarm bells about the 'rationing' of health care.  We all know that it's already rationed.  Maybe there are some situations where even more "rational" rationing is not a bad thing at all.

Incidentally, I do know that the huge amount of time we spend processing, labeling and verifying over-the-counter medications for state plans is ridiculous. Forget the computer entry, the labeling, the piles of stuff to check, the impatient insistence and shouts of  "Is it READY YET???"  Let me hand the customer a bottle of Tylenol, tell them how many to take, and bill the state for one "over-the-counter" charge or some such thing.
No waiting, no labeling, no screwing around. 

Lately I am seriously questioning how long we can sustain this.

Monday, June 18, 2012

And I remain........

"I don't have my card, and I don't know the number!"  chirped the young lady as she checked in
to pick up her electronically-prescribed prescription (thank God she wasn't responsible for bringing
us that piece of paper, either).  Why doesn't this situation EVER get better?  It's becoming more and
more expected that part of our 'customer service' is figuring out people's insurance for them.  What other
business that relies on 3rd-party payers is run that way?  And if your prescriptions are completely covered
by the state?  Well, if I had a little card that allowed me to walk away from the pharmacy counter with
hundreds of dollars of medications at no cost to me, you can be damn sure I would bring that card
with me.  And if I got a new card in the mail, you can be damn sure I'd bring the new one too.

I remain glad to see the abuse/overuse of narcotic prescriptions getting some attention. The amount
of time I spend every day on C-II drugs (double-counting, inventorying, logging, re-ordering)  is
getting SO out of hand. I'm forced to keep huge inventories of these medications and I still can't keep
up. I remain mystified as to the ultimate plan for my customers gobbling up OxyContin for back pain.
We had a customer cheerily remark the other day "Yah, some a' these pharmacies are gettin' in trouble
with all these drugs, eh???"   Yeah, dude, we pharmacies are the troublemakers.
And what was this customer picking up?  OxyContin.  Never did figure that one out.

I remain convinced that one of the solutions to our health care costs has to be the outsourcing
of 'minor' ailments --- to 'quick clinics', non-M.D. practitioners, and to pharmacies (by way of
a third class of drugs that pharmacists can prescribe or dispense on their own.)
I think many of the doctor visits that Americans engage in (in my world, anyway)
are unnecessary and wasteful.  People don't understand the costs.  If they did, I hope they
would think twice about rushing to the doctor with every little sniffle or skin rash -- that way,
there would be more money to include the uninsured people who don't go to the doctor at all.

And finally, with the statins we've made great strides in cholesterol management and cardiovascular
disease. The next great frontier ----  sugar.  Any pharmacist can tell you how buried they are with
blood sugar medications, diabetes meters, testing strips, lancets ----  the time and money that goes
into diabetic and pre-diabetic teaching and monitoring; doctor visits, labs, insurance hassles (don't you
love it when they all of a sudden decide to stop covering one type of meter and you have to switch
people to a totally different system --- just because? And their old supplies -- well, I guess they go into the
trash).   It is staggering.  So if the mayor of New York says restaurants can't sell 20oz. sodas anymore --
it's OK by me.  Baby steps.

Monday, May 7, 2012

O, Omeprazole!

The talk about establishing a third class of medications -- not requiring a prescription but being sold only after pharmacist consultation --- is (I feel) a worthwhile attempt to bring down some of the costs of health care in the United States.  Canada and many European countries already do this.  We already have a multitude of prescriptions written by non-M.D. prescribers, and to be honest, I think I am at least as qualified as some of them to offer someone an ounce of triamcinolone cream or some 600mg ibuprofen tablets.  No, I am not trained in diagnostics or physical exams and would never attempt to do anything I'm not qualified for.  But at this point in my pharmacy career I've probably seen hundred of thousands of prescriptions and inpatient orders --- and I HAVE been paying attention.

I think about this as I am checking my 70-millionth prescription for omeprazole, which is a product that is freely available over-the-counter but is still covered on many prescription plans. I think about the salaries of the technician who processes it, counts, labels and bottles it, and the pharmacist who checks it.  I think about the overhead of the pharmacy that stocks it.  I think about the salaries of the person who receives the patient's request for a refill, enters it into a computer, and the nurse (or sometimes pharmacist) who reviews it -- then if it doesn't fit the criteria for them to approve, bumps it up the ladder to the prescriber.  He/she approves it, hands it off to the nurse/secretary/whatever who generates a prescription or prints or faxes it or calls the pharmacy and the cycle is repeated.  In this case, all the people involved in this cost way more than the medication itself.

So many of our customers visit their doctors for minor, uncomplicated issues. Obviously, everyone has to know when to draw the line and realize when something is more than 'minor', but it seems to me that many of the prescriptions we process over and over again do not warrant the involvement of our vast, hugely expensive health care system.

When a perfectly healthy person wakes up with red, itchy, burning eyes one day -- well guess what, it's probably pink eye, probably viral, and probably will go away on its own in a few days.  Most people will still go to the doctor for this, or at least some kind of walk-in clinic type of place. How about if they could come to the pharmacy, get a 3-day supply of antibiotic drops (useless for a virus, but at least they feel like they are doing something) with instructions to see their doctor if it's not better after that.  The vast majority would be just fine and never come back.  Done.  Lots of money saved!

The time involved in processing, filling and refilling prescriptions for things like prenatal vitamins, the aformentioned prescription strengths of ibuprofen and naproxen , even things like Flonase nasal spray -- seems to me to involve too many people, all of whom are expensive.   Don't get me wrong, there are plenty of sick people out there -- doctors and hospitals aren't going out of business any time soon. But I think there should be some intelligent assessment of many of the routine prescriptions that occupy so many people's time all the way up the chain.  Time, paperwork, overhead, equipment, bottles, labels, insurance claims, personnel, physical plant -- it all adds up in that tiny li'l bottle of Polytrim eye drops.

And by the way, ENOUGH omeprazole!!

Wednesday, April 11, 2012

A Head-Scratcher

The topic of prescription drug abuse has been in the news more and more lately, although to most pharmacists it is not a new topic. All of us have seen customers descend into this hellish cycle. They keep coming in with ever-increasing dosages and quantities or more potent drug prescriptions, and each time they look just a little bit worse. I'm not talking about the "pill-mill" prescriptions -- I'm talking about legitimate prescriptions from doctors we know and patients we know -- but they have entered this cycle that no one seems to be able to stop. As a pharmacist I feel completely helpless, and unless there's something illegal going on I am often at a loss to intervene, and often my input is not greeted with much enthusiasm.

There was an interesting article in the New York Times a few days ago, called "Tightening the Lid on Pain Prescriptions" (check it out online). A couple of things stood out to me:

Quote #1:

“If doctors understood how hard it is to get patients off of these drugs, they would not prescribe them to begin with".

I tend to agree with that, and I've often looked at someone's first Oxycontin prescription with great trepidation (Doc, are you SURE you want to do this?). I'm not a physician and I can only imagine how hard it is to see a patient with chronic pain who answers every drug name you suggest to them with the words "doesn't work." But I also question starting someone on powerful narcotic medication without a plan. How are we going to get them off it?

Quote #2:

"The long-term use of opioids to treat chronic pain is relatively new. Until about 15 years ago, the drugs were largely reserved for postoperative, cancer or end-of-life care. But based on their success in those areas, pain experts argued the medications could be used to treat common kinds of long-term pain with little risk of addiction."

WHAAAAAA????????? Little risk of addiction???? Here's where I'm scratching my head. Can someone explain how chronically dosing someone with a known chemically addictive substance poses little risk of addiction? It's true that many of these drugs were originally marketed for end-of-life care (OxyContin, MS Contin) or serious pain in a hospital setting (oxycodone, hydromorphone, fentanyl, etc.) Now they have leaked out into the community and into the realm of family-practice doctors who are prescribing them for neck pain, back pain, knee pain, TMJ, migraines and a bunch of other stuff for which they are not intended.

The NY Times article concludes with this:

"If the patients were taken off the medications, many would experience severe withdrawal or have to take addiction treatment drugs for years. Even avid believers in the new direction, like Dr. Ballantyne, suggest that it might be necessary to keep those patients on the opioids and to focus instead on preventing new pain patients from getting caught in the cycle.

“I think we are dealing with a lost generation of patients,” she said."

Monday, April 2, 2012

It's not about the broccoli

Y'know, it was really disheartening to hear one of the current presidential hopefuls sneer that it
was 'snobbish' for the current President to encourage people to go to college (actually, all he said was that people should aspire to at least a year of post-secondary education or training.) There are some days when I am overwhelmed at the questionable level of intelligence demonstrated to me by some of my adult, fully grown-up customers. For example, the ones who know they have a large packet of new insurance information at home but don't feel it's their responsibility to open the envelope. The ones who seem unable to follow simple directions, read what is written or listen to what is told to them. They are entitled to SO many things, but don't have to hold up their end of the bargain. They don't have to study, learn, remember or pay attention. They are spectators -- it's someone else's job to do it for them. Oh, and then there are the emails from my own managers and superiors that are written at a 4th grade grammar level and full of spelling mistakes. It really gets me down sometimes.

My apologies for not posting too often lately -- I was lucky enough to take a vacation to Europe and as always, enjoyed making some observations about health care. Pharmacists are a first-line resource for health care over there, and that makes a lot of sense to me. How many people do we see coming from a doctor's appointment clutching a piece of paper on which the doctor has
scribbled "hydrocortisone cream", or "Benadryl" or "Sudafed?" There are a lot of people who go to the doctor for minor things because they simply don't know what else to do. I guess they don't trust anyone but a doctor to tell them what to take. People have to understand how expensive this is. And then there are stories like the one Dr. Grumpy linked to, where a guy called 911 because he had scabies, and the full force of the American Health Care System weighed in to the tune of a thousand bucks. It's madness.

I had a conversation with someone in Britain who needed to go to an 'urgent care' clinic for
some severe traveler's diarrhea. Yeah, she had to wait a little while (just like here), but was seen by a clinician who prescribed totally appropriate treatment, handed her the box of antibiotic tablets (no pharmacy visit involved), told her what to do and she went on her way. No money changed hands and no bill was generated. I know it's just one example, but it seems pretty simple (and a lot cheaper) to me.

What's missing in the health care debate are the voices of the people who actually work in health care. Why don't we see them on TV instead of a bunch of extremist political pundits screeching about losing their 'freedoms?' I simply can't watch it anymore without getting depressed, yet I probably have an obligation to watch. We spend more on health care per person that any nation in the world, and get poorer results when it comes to basic preventive care. How do we get that through to people who can't understand the words "THIS CARD REPLACES YOUR OLD ONE??"

Monday, February 13, 2012

In The System

Well the beginning-of-the-year nightmare scenario has eased somewhat, however I'm still getting customers who positively assert that they have been to my pharmacy many times before, and that all their current information is 'in the system.' Alas, a quick check of the system reveals no record of them whatsoever. Are people really not paying attention to where they are on this earth?? When you can't remember where you have had prescriptions filled, you're getting way too many.

Erratic staffing forces me to spend much more time at the cash register than I ever want to. I barely make it to the window when the person is swiping their credit card with a giant wave of the arm. Please, wait a minute. Let me at least tell you how much it is --- that way, we won't complete the entire transaction before you think to ask me "Why is it that much?" or "I think I won't take that one." Because you know, to reverse a credit card charge is about a 20-step process on our incredibly complicated register system. And incidentally, I've already given up on the idea that you might want me to tell you something about your prescription.

A couple of things that people still don't "get":

--- Dropping off seven new prescriptions means you're going to be waiting awhile. Don't look so surprised. There are people ahead of you, and the staff here still have to wait on other customers and answer the phones while we plow through those prescriptions. Come back later.

-- For a doctor to continue to prescribe medications for you, they generally have to see you for an appointment at least once a year. That's the way it is -- snapping at me that you NEED it, or you don't want to pay an office copay is not going to change it.

Hell hath no fury like an entitled, middle-aged guy who suddenly discovers his Viagra is not covered on his new insurance plan. Jeez, I had a tough time keeping my cool with that jerk. He was incredulous that the doctor's office had not responded to the request for a prior authorization the next day. Move to the back of the line, EVERYONE. This guy goes first.

A lot of people are writing prescriptions now who are not M.D.'s (as Pharmacy Chick referred to in a recent post.) Many of them are very competent and save the system time and money by treating medical conditions within the scope of their practice and under the 'supervision' of an M.D. However, some of these prescribers write for some heavy duty stuff, and I am really uncomfortable filling prescription after prescription for C-2 narcotics from a nurse practitioner. Sorry, I just am. I had a customer decline (with my blessing) to fill a $250 inhaler the other day from an NP, stunned that this had been prescribed for a "little cough." Or the guy who said he was switched from simvastatin to Lipitor, merely so he could "eat grapefruit." (??) Another NP near us seems compelled to write multiple prescriptions for everyone, and I think only succeeds in confusing the hell out of people.

Me included.

Monday, January 23, 2012


OK, the end of January is approaching and I can't get over the feeling of just spinnin' my wheels.
Work has been an endless parade of insurance rejects...." patient not covered....ask patient for new ID card..... non-matched cardholder.....refill too soon......we are rejecting this claim because it's a day with an 'r' in it, ha ha !!.....and a million other reasons that I've never even seen before. People who have completely changed insurance plans, did not bring the card, and expect me to figure it out for them. I ask people POINT BLANK when they drop off their prescription, "HAVE YOU CHANGED INSURANCE IN 2012?" They reply, "no, nothing has changed." Fifteen minutes later we finally get to their prescription, it rejects, we ask them about it and they say, "yeah, I have a new card." Honestly, I feel like I'm being punked in a reality show or something. And of course the person's next question is, "Is it ready yet?" Things never change.

The prescription transfers are still plentiful. As usual, people don't understand that this takes extra time. I feel bad about calling the same pharmacies multiple times a day, but what else can I do...

Anyway, the other things on my mind are:

--Staffing. Why do we never have the right amount of people when we need them? One of the busiest times in retail pharmacy is between 4pm and about 6:30 pm, when people are picking up prescriptions on their way home from work. Working people, as well, tend to want to schedule doctor's appointments at the end of the work day so they don't have to miss too much time.
Day after day we get slammed at the same time, we don't have the proper staffing, we rack up overtime and get our hands slapped for it, like we are incompetent or something.

-- Security. I never thought about it much before, but I'm becoming more aware of security lapses in the pharmacy and no one else seems to care. It costs money to beef up security, so it's not something I can do without the company's help. I really don't want us to learn the hard way.
I'm trying to figure out how to approach this without stepping on anyone's toes or sounding alarmist. But I'm going to keep at it.

-- Getting fired. It actually happens! We've had two support staff members get fired in the last couple of months. You would think people want to hang onto their jobs right now, but apparently the mere threat of firing wasn't enough for these two. I'm glad someone in the company actually has the balls to do it, but there are still other people who inexplicably get a pass.


Sunday, January 8, 2012

Happy New Yea------- Oh, wait.

Aw yuck. What a hellish "new year's week" it was.

It included a major software change in the way we submit on-line claims to insurances. The end result, in a nutshell, is that there are approximately 1,000 new and different ways for a claim to reject, and I think we saw every one of them.

It included the usual insurance plan changes for customers, with the associated freak-out when
their new copays were revealed to them at the cash register. "But I've always paid (X) dollars!!"
was #1 on the week's hit parade. #2 was, "I don't have a deductible!!" followed by a grumbling
return later in the day, after they had called their insurance company.

It included one of the major corporations in town switching to a new pharmacy benefits card.
I don't even work for them, and I knew about it months in advance. These employees are educated, white-collar workers -- some are even health care professionals. Do you think even ONE of them had the card with them when they came in? Do you think the majority even understood that the benefits they signed up for during open enrollment screamed "CHANGE" ? Alas, no.

And of course it included the transfers out of Walgreens for Express Scripts customers. Most of the Walgreens I called had a message asking me to leave the information for the transfer and they would fax it to me. However, since no one plans ahead and many people wanted it while they waited, I had to ask to speak to someone right away. To my surprise, all the Walgreens pharmacists I talked to seemed pretty darn nice about it. I can't imagine how they are dealing with all that.

It also included assorted other computer glitches I don't even want to get into.

One of my co-workers said she felt like crying. Me, I had to fire up the ol' cocktail shaker
at the end of the week. Simple, yet effective.

We shall steel ourselves for the week to come.