Road Trip!

This year's March break took the form of a road trip -- a pretty long one at that -- about 1200 miles passing through the Midwest and into the Southeast. I've done this drive before, but usually when it's hot and the cornfields are planted and well on their way.
Looking out the car window, there are a few things I noted:

1. Burger, burger, burger. Every exit off the interstate has a McDonald's, Wendy's and Burger King. There are some pizza places and Subways, but I'd give anything to avoid consuming 800-1000 calories in 5 minutes and then return to sitting on my butt for another 4 hours.

2. A lot of people across this land live in mobile homes or small modular houses -- we are a wealthy nation, but most of us aren't wealthy. The number of RV's sitting outside is striking too. A lot of them look like they haven't moved in a long while. But for many people, an RV is how they vacation -- they don't jet off to some distant land and stay in a hotel.

3. The truckers and truck stops. As the slogan goes, trucking really DOES move the nation. There are countless numbers of them, and late at night I think it must be a gritty, lonely job.

4. The number of places that are open 24 hours. Pharmacies, restaurants, drive-thru's, grocery stores. truck stops, gas stations --- always someone working late into the night hours.

5. Getting the farm fields ready for spring. Seeing two Amish men out in a field with a horse and plow. The young Amish woman sitting reading a book when we went into her store to buy some jam.

It's a very diverse country we live in. I just find it interesting to observe, whether you're standing in the middle of Times Square or driving through West Virginia coal country.

Now, back to work --- and no more burgers for awhile!!

Puh-leeze Read the Signs

The car wash I use has an automated pay station located slightly around the corner from the entrance to the car wash itself. You pay, and then a large green arrow lights up when the car wash is ready for you to drive in. There is a large, clear sign on the pay station: WAIT HERE UNTIL GREEN ARROW LIGHTS UP. So I watched with amusement as every car ahead of me paid, then plowed ahead and waited inches from the closed door to the wash. Of course eventually the sequence of payments got totally screwed up and the wash wouldn't open at all until the cashier came over the intercom and got things re-aligned, reminding everyone of what the sign said. Sigh.

Why don't people read the signs? We've all had the customer who spots you in the pharmacy and pounds on the window "ARE YOU OPEN??" when their pounding fist is literally inches away from the sign that states the pharmacy hours of operation. Public places, including medical clinics and pharmacies, are full of signs that are gleefully ignored:

Pick Up
Drop Off
Please present insurance card with prescription
For the privacy of the person ahead, please remain behind this sign
Please check in with pharmacy staff if your prescription has been sent by your doctor
Leave lab slip here, ring bell once, have a seat

.. and so on

Someone I know who works in a museum always stresses the importance of signage.
Its purpose is to give people direction in an unfamiliar place and to improve the success of that place by keeping people moving efficiently through it. But you've got to stop for just a minute and READ -- you've got to take just a second and OBSERVE, and that's the problem.

We deal with lots of people who are distracted and in a rush. There are lots of non-English speakers too (although many of our signs are in multiple languages.) I think there is a subset of people who just outright refuse to 'follow' the signs, though. You can spot them a mile away. One good example is the alpha male type who isn't going to be told what to do and certainly isn't going to be part of the 'herd.' It's ME first, and I don't have time to read your silly signs so you will have to give ME your personal attention. These are the ones I dislike the most. Nobody's trying to boss you around, your Royal Highness, we're just trying to make things run a little smoother. Just take a second and read the sign.

Random Things that Made Me Go Hmmm.....

A parent who rushes in to pick up a brand new prescription for a bed-wetting child who's going on a school field trip (like, leaving in a half hour). We don't have the strength they need, we call around to find it, get the Dr.'s office to re-send the script to the other pharmacy, and she rushes off. Hmmmm. You mean she's going to send this kid off on an overnighter with a brand new prescription he's never taken before and hope everything goes fine?

A female patient being checked out with a new prescription for a psychiatric drug. Paid up, ready to go, and then mentions that she and her husband are actively trying to get pregnant, and that she didn't mention this to the doctor. Hmmm. That definitely would have been a good thing to mention somewhere during the discussion -- this isn't M & M's we're taking here. In fact, we check the literature and find you don't want to be taking this drug during pregnancy, especially the early stages. We pony up with a refund and she decides to call her doctor tomorrow.

It's chaotic, and we're having the usual back-and-forth-question-and-answer discussion with a customer to try and determine the insurance plan to which we bill their prescription. Phone calls, trial and error, a few more questions, doctor NPI search, several interruptions, customer hovering and waiting expectantly and being told it's gonna be a few more minutes and we'll call you when it's ready and finally we are ready with the prescriptions and applicable co-pays. Customer looks wide-eyed and then informs us he didn't bring any money with him. Hmmm. I want to pound my forehead on the counter.

A customer who squawks about a 3.00 copay comes in for an antibiotic which, she informs us, is for an infection she contracted from a pedicure. Hmmmm. I've never had a pedicure. How much are they?

We always double-count controlled meds that are dispensed by the Scriptpro (automatic 'counting' robot machine). I decide to randomly double-count some other meds too. Every single damn one seems like it's off by one or has broken tablets or fragments in it. Hmmm. I wouldn't blame a customer at all for getting mad about that -- they're paying for it, after all. But we don't have time to double-count all of them, so I hold my breath and hope.

I LUV my great technicians, but I worked with one this week who I don't see that often. Every time she prepared an antibiotic suspension or tube of cream she covered up every pertinent part of the manufacturers label (that I obviously want to see in order to check the thing) with our store prescription label and wrapped it in enough tape to seal a mummy. I don't mean to be picky here, but when I check something I like to see the original label, NDC number and bottle size. Hmmm. I can't see through your label and I sure as heck can't peel it off through all those layers of tape. Maybe I could dig through the garbage to find the box? Whaddya think I'm doin' over here anyway? I'm checking! I REALLY AM!

New Drugs, Old Drugs and Borrowed Drugs

I usually try to be nice to drug reps, unless they are really obnoxious, condescending, or try to tie me up when I'm obviously really busy. They're just people trying to do a job (one that I would not want). Some of them are nice and even thank me for my time, and jeez, how often does someone do that? I guess I'm just a sucker for anyone who even fakes respect for me.

I got a visit from the Kapidex rep last week. I mean, I felt bad for the guy even having to TRY and sell this stuff. This is the new R-isomer of Prevacid -- another example of the many 'new' drugs which take an existing drug and tweak it a little to make it sound brand new and different.
You take that existing drug and you market the isomer, prodrug or active metabolite and promote it as the next best thing, especially when the original drug is soon to go generic. And the company offers a discount card for $55 off on Kapidex -- so you know if they are knocking $55 OFF it already costs too much. You look at all the glossy literature and you think, this is an especially unfortunate waste of resources in these tough times. I mean, seriously? I can't wait to see the TV commercials.

The other one out there in the TV commercials now is Oracea, a "unique" formulation (ie. lower dose) of doxycyline, another drug that's been around since the Stone Age. They were even running an ad on my TIVO service. I don't see too much hope for a market share for either of these drugs -- insurances will give them the cold shoulder --- but we'll be forced to stock some eventually and then allow it to expire.

Speaking of old drugs, I'm interested to see if the FDA will pull Darvon and Darvocet-N products. I remember being told in pharmacy school that propoxyphene was a pretty mediocre analgesic with more risks than benefits and I've never been real excited to dispense it to anyone. We've already had a customer panicking on this one.....

Customer Service or Not?

This is sort of an extension of a topic I've written about before, but it continues to be an issue in my workplace (which is a string of clinic/medical office building pharmacies, not a big corporate chain.) The organization is feeling the economic pinch and loss of revenues, just like many others. Our business is still quite steady, but cost-saving measures and ways to maintain our business are always at the forefront.

Some of the staff don't give a rat's ass and continue to do their job as they always have. But some of the 'good' technicians are conflicted as to how far they have to go to cater to people who don't present adequate insurance information, and they get varying directions from the pharmacist managers they work for. Some technicians feel they are now expected to get on the phone and track down insurance information for everyone who claims to have it --- they just don't have a card or don't know why our information is rejecting. Otherwise, the customer is either expected to pay cash price or (more often) walks out the door. It's slowly creeping into the realm of "customer service."

I'm conflicted about this. Don't get me wrong, I know that pharmacies are not obligated to verify insurance, period. That information has to be supplied by the customer. We don't expect the Target cashier to call our bank to get our credit card number. And the big chain pharmacies doing 800+ scripts a day have absolutely no capacity to do this -- the wait time on a prescription would be about a week! I get really annoyed when someone expects me to bill an insurance they can't produce. Being in a clinic environment, we do sometimes have access to more information than an outside pharmacy would, but I have actually told technicians on the phone with insurance, "look, we're just getting too bogged down here -- just give the customer their options. We can't solve this for them." But the technicians will tell me some pharmacists expect it of them, especially the managers in some of the smaller stores who are worried about their prescription volumes.

So I guess I'm not sure where to draw the line between being helpful and facing reality. I'll call an insurance provider if I believe it's something I can solve relatively quickly. Some of the insurance companies have websites, but the first thing they want is the patient's ID number and that's usually what you don't have. If it's a regular customer who's well known to me, and all of a sudden their insurance doesn't work, I'll try to help them. But I do NOT want people to expect this, and many of them now seem to.

Oh yeah, and if that prescription is $4 you can be darn sure the Insurance Detective Service will NOT be offered....

The Obesity Epidemic

There are some days when I am really taken aback by the number of our pharmacy customers who are seriously, morbidly overweight. They are young and old, male and female alike. I have to wonder what it's like for them at their doctor visits --- is the doctor laying it on the line? --as in saying, "Most of your health problems and the majority of your prescriptions could be eliminated if you JUST LOST WEIGHT." I know it's easier said than done, and doctors probably repeat it over and over (perhaps at some point they have to give up), but it is so true.

You look at the meds these people are on. A serious weight loss (and for some, we are talking 80-100 pounds that needs to go) would mean they could probably cut back or eliminate meds for blood pressure, blood sugar, joint pain, depression, breathing & wheezing, fungal skin conditions and many more. Next to quitting smoking, weight loss has to be the #1 best thing you can do for your overall state of health (that you have control over.) It seems so simple, but of course it isn't....

Most of us would love to drop 5-10 pounds anytime, but the folks I'm talking about are way past that. And you know the sad part is that exercise is out of the question -- they can barely MOVE. Where the heck do you go from there, other than into surgery? Way easier to just not let it get to that point. This kind of weight gain doesn't happen overnight and you wish these people would have looked in the mirror honestly a few years ago and said, I gotta change this.
It is a uniquely American predicament. I've been lucky enough to travel to some other parts of the world and I am struck by the fact that looking around you, you just don't see the fat like you do here.

My Inner Voice helps me haggle over a price

We who deal with the public have to try and be polite even when the person we're dealing with is not. But that doesn't mean we don't have an inner monologue taking place that doesn't match the words that are actually coming out. Hey, it helps! A recent patient encounter of mine:

Young female customer picking up refill prescription (non-essential, I might add) for which she is paying cash price:
Has the price gone up?

My Inner Voice: I have no idea. I don't set the prices. I don't know who you are or what you paid the last time.

My Actual Voice: Well, it could have. Our prices are set by the head office in response to increases in what we pay for the drug.

Customer, sourly: Do you send out letters to people without insurance when your prices go up?

My Inner Voice: Sure, lady. Right you are. We actually mail out thousands of letters every week to all our customers who we've determined don't have insurance to let them know of price increases. In fact I just finished putting the stamps on myself.

My Actual Voice: No, unfortunately we don't have the capability to do that.

Customer, rolling her eyes: Well, that's convenient.

My Inner Voice: OK, you have now crossed the threshold into snottiness. Do you want the damn thing or not?

My Actual Voice: Well, we can hold the prescription if you would like to price-shop around.

Customer, sourly again: Well no, I need it.

My actual voice: Thanks, have a good day.

My Inner Voice: Go away now.