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Monday, June 9, 2014

Behind the Curtain

In The Wizard of Oz, the Great Oz tells everyone "pay no attention to the man behind the curtain". In pharmacy however, a lot goes on behind that curtain that warrants your attention. So far I have focused on why things take so long and what exactly goes into filling your (just your one) prescription. Today we will examine what exactly occurs behind the scenes that we need to do to get your prescription ready for you on time.

If you are a loyal follower then you probably know it takes a lot of work to get your prescriptions filled. However we receive it, electronically, fax, phoned-in, you personally delivering it, Pony Express, we need to start with the hard copy of the prescription. This is the order from the doctor that tells us what to fill. It's all downhill from here. Anymore, there is an issue with most prescriptions we receive. The first thing we need to do is call the doctor for clarification; on the patient name, the drug name, the strength, the directions, the quantity, the refills, the doctor who signed it or even the date it was written. Then we either get an answer immediately, are put on hold for someone to check the chart, or have to wait until later that day or days later for a return phone call. Sometimes, we will get a new electronic prescription to replace the wrong one only to find out it's the same error or there is a new mistake. Sometimes doctors will send us multiple copies of the same prescriptions. Sometimes they will make changes but not call to cancel the original ones. Sometimes they will send multiple ones to multiple pharmacies because they thought they didn't go through. Either way, we have to cut through the static, decipher their intent, then fill the correct one for you. This takes time.

Then it may need a prior authorization. We will fax the doctor the request. He will contact your insurance, if he really wants you to have it. Then the insurance will make a decision and notify the doctor. Sometimes the doctor calls us when it's ready. Sometimes they do not. Sometimes there are great offices that do a great job of getting these approvals instantly. Sometimes, not.
Sometimes we do not stock a particular medication. We can usually determine whether or not you need it that day. We will often call another pharmacy trying to locate it for you. Often, we will call your doctor for an alternative that we have in stock that will work for you.

Insurances: Maybe we have to call because a set of twins, or triplets, is trying to get the same prescription filled for each child. Since they share the same date of birth, the insurance thinks they are the same person. This necessitates a call to them pleading on your behalf that there are really 2 or 3 of them.

The point is this: There is so much that we do that most people are unaware was required to fill their prescriptions. When things run smoothly, no one notices. It is only when the system hiccups that everyone can see the machine's inner workings going a little wonky. I'd like to point out the little things we had to do, but I chalk them up to "that's what was required and it's my job to do this for you". That does not mean I haven't pointed it out to someone who is a little testy about his wait time.

CP: Yes sir. Your doctor did send it over to us an hour and a half ago. However, in that time, I had to call him back because he sent the directions over as "take one tablet by mouth every morning before breakfast twice a day (bid)". I was confused. Does your day have two mornings? And why did he bother telling us to dispense 120 tablets for a 90 day supply? At once a day, that's a 120 day supply. At twice a day, that's a 60 day supply. Then your insurance wanted to know why you were coming in too early for the refill. At once a day they were correct. Now that it is officially twice a day, they were okay with the explanation of a dosage increase. I am terribly sorry your doctor started it off wrong by sending us a flawed prescription. I am sorry he gets to take an hour and a half lunch and he sent the order while stuffing his face on said lunch. I am sorry you would rather have the prescription dispensed to you incorrectly than have to wait. The odd thing is, had you come in 5 minutes later, it would have been ready and you would have had no idea what all we did to fill it for you. Also, had you gone home first, you would have heard the message from us that we were working to fix your prescription so call us before you come here.


  1. long time reader, first time commenter and a physician.
    you are correct, my office allows for 1.5 hours of having no patient scheduled. that does not equal lunch. that equals running behind because the 15 minutes per patient I have scheduled is almost always not enough for the multiple complaints, or my favorite, here for a URI and also horribly depressed and suicidal. it equals charting, responding to patients' family members' and pharmacists' phone calls, hospital calls, patient emails etc. lunch is often eaten standing up bite by bite in between patients. I understand your frustration and thank you for catching our mistakes and taking the time to clarify, but I imagine the average PCP is not much different. the common denominator is the health care "consumer" who doesn't see our profession as anything more than going to the convenience store.
    sorry for the soapbox, i just wish i could sit down to lunch too :)

  2. 1) Patients need to be RE TRAINED in being responsible for their own insurance...reading the enrollment info, reading the copay cards, reading the disocount cards...some need activation, knowing what drugs are covered on their plan...heck take a current printout to the docs office of approved drugs, I deal with hundreds of insurances, they all don't cover the same and I dont have their lists memorized. Why is it my job to call your insurance to find out what's covered then turn around and have to call your doc to get the script changed meanwhile you're telling me it's all MY fault cause I should have known this PUUULEEZE.
    2) WE (doctors and RPhs) need to fight back at this McD's mentality of healthcare instilled by corporations and insurance companies in this country. Studies show on both sides..mistakes are made when one is forced to do way too many tasks at one time and too many distractions.
    3) Stop the drug ads on TV...that's another reason we have "IT' drugs, people see it on TV and think 'I have that I should be on that drug because the one I'm on must no longer be good enough" No wonder drug prices are so darn high.
    4) Prior Authorizations: I think we need to double down on our efforts to firmly enforce that these may take AT LEAST 2-3 BUSINESS days. If you bring me one on a Saturday, I guarantee it wont be touched til at least Monday, maybe Tues because I know how busy a docs office is on a Monday. I do my best to tell my patients out of refills, don't bother checking back til Tues because Mondays at any docs office is swamped on Mondays, If they're lucky I might get it Monday night.
    OK, I'm off my soapbox

  3. Okay, my soapbox time.
    As a spouse of a CPhT, I have heard the horror stories from different angles. Although at times I play devil's advocate with her, I totally sympathize with the workers in this industry. As a Psychologist (not Psychiatrist), I can see the forest for the trees, but as a husband I can see the affect of a foreign body on a single tree in the forest and how it can spread like a disease to the other trees (i.e., the bark beetle or an organic fungus), and how the remedy (insecticide or fungicide) is like company policy that just gets built up on top of each other to confuse the whole picture. I know I'm talking in metaphors and I hope I'm understood, but In the end, I have to comfort my wife who's on the verge of breaking down emotionally and wonder what career is really worth this upheaval. I can only reassure her that it won't be long till she doesn't have to do this anymore and pray she won't pick up some new hobby like gun collecting.
    But is any job worth this? Is there any point in waking up in the morning and going to a job where you know you're under-appreciated? I guess that would apply to any service-related industry job. The only thing I can do as an observer is to have an understanding of what the process is and work with the clerks, CPhT's, RPh's, and anyone else involved in getting my prescription to me to ease the anxiety and frustration created by others that are impatient.
    I just hope there will be enough Lorazepam and Clonazepam to go around.