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!

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. '

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?

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.

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.

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.

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!!