How to Make Money in Pharmacy Without Really Trying

I like making money.  For the last decade at least this has not been a problem.  With an over-saturated market of licensed pharmacists and lower reimbursement rates from PBM's and state and local governments, retail pharmacy needs to find ways to make more money.


I realized that a lot of people take credit for things they already do.  They also have figured out how to charge for these things that they used to do for free.  For example, airlines used to fly your bags for free.  The space was empty anyway and you were seated just above them headed, most of the time, to the same destination.  When they realized they needed more money, they started charging for the bags to tag along.  


How can this translate to the world of retail pharmacy you ask?  It's called " a la carte pricing".  It sounds better than fee-for-service but hear me out on this.  If doctors require us to fax them for refills and look up prescription information even though they have a chart in their office, I am going to charge them for these services.  I know.  This was in the last few blog entries but this is where it gets good.  The examples will look something like this:


     Patient is Responsible for:

•      Handwritten Rx's--------------------$2.00 each
•      Rx Too Old---------------------------$1.00

     Offices Responsible for:


     If we have to call your doctor because information in missing or incomplete:

•           Wrong/Missing patient name----------------$3.00
•           Missing drug or strength---------------------$3.00
•           Illegible/Missing Directions----------------$5.00
•           Quantity missing----------------------------$2.00
•           Refills Unclear-----------------------------$0.50
•           Not Signed--------------------------------$25.00
•           Forgot to select anything on a preprinted Rx where all he has to do is check a box----------------------------------------------------$15.00
•           All Refill Requests you Require me to fax---$1.77
•           Looking up Refills you are Calling in to me-$8.23

     Computer-Generated or Faxed Prescriptions--Flat fee of $11.38 per occurrence

•           Wrong patient
•           Quantity (N/A)
•           Drug/Directions Mismatch (take 5 mg tab intravenously)

All prescriptions are required to be completed electronically and either sent electronically or faxed according to state and federal laws.  They may be issued to a patient directly, but please do not forget to sign them as per your state law.  Phone-in prescriptions will be free, for now.  The exception to this is offices that employ nurses who have an ADD-type disorder and omit information regularly in which case the above prices will go into effect.  Also, if your nurse does double-duty as a Micro Machines pitchman or commercial legal representative on TV or radio ads and I can't understand a damn word she says, please read the pricing chart above.  


Since we are already performing this task, we might as well get our piece of the pie too, right?  Insurances can't complain about this since it doesn't affect their bottom lines.  What are doctors going to say?  Let's think about this.  
     1. I don't like you charging me for forgetting to sign my name.  I'm a doctor!
     2. I don't like you charging me for always entering N/A on the quantity line when it should auto-compute.  I'm a doctor you know!
     3. It's not my fault you can't read the Prednisone taper I clearly wrote, even though it doesn't say for how many days and the quantity is "QS". I always write it that way.
     4. It's not my fault the computer put Oxybutynin ER first and I wanted the regular.  You should just know that because it's cheaper.  


It may seem petty, but how long have we given away our professional services?  We have automatic refill systems, auto-faxing to doctors for refills (which used to be a courtesy), and reminder calls to fill and pick up your prescriptions.  How much else are we willing to give away for free?  
This is not anything more than an attempt to be compensated for our time and energy.  This is time and energy that have to be redirected to fix something that never should have left your office in its current condition.  
    

Pharmacist vs. Doctors, the 3rd

And another thing...If you, Dr. Zoffis, are calling me, Herr Pharmacynic, to authorize refills, confirm prior authroization approval, give new prescriptions, or do any other professional work, please be prepared.  Let us remember the healthcare cycle: patient goes to doctor, doctor writes prescription, patient brings Rx to pharmacy, pharmacist fills Rx.  When refills are done, we go back to the beginning.  This means everything starts with you.  The doctor.  Lather, rinse, repeat.  


I implore you, as a former Scout, Be prepared!  Again, I do not work in your office but if you expect me to do your work I am going to have to charge you every time I have to have this conversation:


     Nurse: Calling in to refill a patient's prescription.
     ME: OK
     Nurse: They didn't give me their prescription number but it's for HCTZ.
     ME: OK. What strength?
     Nurse: Can't you just look it up?
     ME: Yes.  But can't you just look it up?
     Nurse: I don't have the chart but it's the same as before.
     ME: Correct me if I am wrong (and I rarely am) but did you not originally prescribe this medication?  And did you not put it in a chart? And if you knew you were going to call me (because I didn't know you were going to make me do your job too before you dialed my numbers) how did you not know I would need all of this information?  If you knew to call me for his refill then you knew you were going to do this to me.  Therefore, I am going to send you a bill for looking up each piece of information you don't have.  How do you know he even (still?) takes HCTZ?  How do you know the doctor didn't change it since the last visit?  Does he get 30 days or 90 days?  Is this even the right pharmacy?  What's his date of birth?  Help me!  Then pay me!
     

Pharmacist vs. Doctor II

Pharmacist.  Magician.  Receptionist.  Thinker.  I can do it all.  Just ask every customer who tried in vain (allegedly) to reach their doctor.  Why does everyone think we can work through to their doctor faster?  


     Patient: "You need to call my doctor because I can't get through."
     Pharmacynic: "Wow.  Neither can I.  I have to call the same phone number you do.  Did you hear the magic 'pharmacists press now to have all your questions answered' prompt?"
     (Im)patient: "Well what am I supposed to do now?  You need to help me!"
     Pharmacynic: "Okay. Revolutionary thought here but bear with me.  Drive. To. Your. Doctor.  Ta-da!


I think all offices should have a dedicated Pharmacist option on their phone lines.  We have an option for doctors to leave voicemails but the most we usually get in return is a refill line.  That doesn't help if I couldn't read a prescription for someone who just left your office and is here now.  It doesn't help with any questions about interactions or answer any questions I have about the voicemail your nurse left just seconds ago.  She is apparently charged for each second she spends on the phone and can't afford to enunciate or spell anything and now I can't get her back on the phone to answer my question.  


Most doctors' lines include options for other doctors or hospitals, for making or canceling appointments, for lab work, for billing questions, a refill line (if they don't require us to fax them), a worker's compensation option, and an option to give hours, services and directions.  Why don't we rank?  If we are expected communicate frequently with these offices, we need a pharmacist-only line.  I have asked some offices if they have back lines and have occasionally been granted these numbers, but only after swearing to not share it with anyone.  Right.  There's a whole black market looking to exploit doctor's private office numbers.  


Make it easier for me to get my job done and your life will be easier as well.  Since you are already expecting me to fax all refill requests and look up the refills you are calling in to me when you have their chart, it's the least you could do.  

Pharmacist vs. Doctor

In the beginning there was a doctor.  He wrote prescriptions.  There was also a pharmacist. He filled prescriptions.  And the world was good.  I am not a doctor, nor do I play one at work.  However, it seems that we as pharmacists have let the lines blur a little too much in what is each person's role in the whole healthcare dynamic.  One of my favourite quotes to customers is "I don't work in your doctor's office and he doesn't work in my pharmacy".  I often use this to great effect after a customer is sent directly over from his doctor after being told any or all of the following: "your prescription will be ready by the time you get there", or "it's on their $4 list", or "Augmentin is only a few dollars, don't worry".  Well, I can't tell you the last time I saw your doctor here, let alone actually spoke directly with him, so don't believe everything he tells you.  


Today I realized it has gotten so out of hand that we pharmacists haven't even noticed we are now employed by every doctor in town.  While waiting interminably on hold (pharmacy hold times aren't always better, I concede), to clarify a poorly written prescription, I heard this message: "We are requesting that all refills be faxed.  Please contact your pharmacy and they will fax us for you".  Another office used the similar "please notify your pharmacy to send a fax to us".  


Excuse me?  What?  When did we allow other people to tell us what our job is? (Oh yeah, when we sold out to mail order and PBM's over the last 10-15 years.  But this is different.) 


Anyway, I have decided that I need paid.  If the doctor requires I fax your refills to her, I am going to send her a bill at the end of each month for every one that I send.   Yes, most faxes are generated electronically but I still have to answer your phone call after you have already talked to the office.  Since the doctors would like to place the onus on us if a refill is not authorized, I would like to be compensated for this responsibility.  We all know that faxes do not get received, doctors ignore them, lose them, forget to sign them, etc.  As I have mentioned before, I cannot fill prescriptions I do not have.  The patients know we are the only ones they can yell at directly and therefore, since the doctor requires we fax them, we must be the most culpable if the process breaks down somewhere.  If the fax number is incorrect or missing or a doctor enters or leaves the practice, I have to track this down for you.  A precedent has already been set in other similar situations.  Doctors requiring pharmacists do NOT send faxes will charge the pharmacy for each one they receive.  Doctors also charge patients a full copay for any refills they require outside of an office visit.  


To further support this, my second resolution is to post on my hold message the following script: "Our pharmacy requires that all new, paper prescriptions be sent electronically or faxed.  Please contact your doctor and ask her to invest in this new technology and to stop hand writing prescriptions as we will no longer accept these."    Perhaps we should charge to fill illegible scratch.  I may be on to something here.  But that's another story.

The Future of Pharmacy

Brothers and Sisters in Pharmacy-Dom, please allow me to show you the future.  Thank you all for being here today.  Prepare to be amazed, dazzled, awestruck, and even a little weepy.  Over the next few paragraphs I shall outline for you the business model that will revolutionize pharmacy practice as we know it.

Having spent a few years in practice and devoting my life to studying the practice of pharmacy, the general public, and the evolution of our customers from thoughtful, reverent patrons to resentful, demanding, impatient douchebags (sorry, "guests"), I have arrived at the following plan for us all.  I call it "Pharmacy As Total Healthcare (P.A.T.H.)" Licensing agreements will be available to all levels of government.

The Basic Plan:  For a regular monthly fee assessed to the patient, we will perform all of the following:

1. Schedule you doctor's appointments for you.
2. Go to your scheduled appointments FOR you.
3. Get your prescriptions from these appointments for you.
4. Take these prescriptions to your pharmacist (me).
5. Fill all of your prescriptions for you.

     As of today, refills will NOT be allowed under this plan.  We will repeat this process on a monthly basis upon collection of the monthly fee.  If you agree to pay the entire year up front on January 1st of each year, we will include refills and add:
   
     6.  Notify you when refills are coming due and start again.

The Basic Plus Plan:  Includes all of the above while also providing

     7.  Deliver all of your filled prescriptions to your house.

The Premium Plan:  this will add

     8.  Have all lab work and diagnostic tests performed FOR you.

The Executive Plan:  will include

     9.  We will keep your filled prescriptions on-site and take them FOR you.  This will minimize side effects and the potential that you will miss doses.

The Platinum Plan:  is only  available for our patients with narcotics

    10.  This will enable us through networking to sell your narcotics on the street FOR you so you need not risk your own life.  As a bonus for enrolling in this Plan, you will earn a 5% commission on sales, the industry standard, which is the same commission provided to our sales force.

You will find this new, innovative model will take the worry out of your life and put the Care back in healthcare.  As you can see, we offer a wide variety of plans to meet your every need and options can be changed as your healthcare needs change.  This program eliminates all of the blocks to quality healthcare in America: no longer will you have to worry about making appointments, seeing specialists, missing medication doses, running out of medication and asking for a few pills until your doctor calls, or even taking many medications and dealing with side effects.  From the safety and security of your own couch, you too can have worry-free healthcare.  We will also know what medications are the most cost-effective for you and formulary-approved through our exhaustive research and collaborative agreements with the largest health insurers.  By forcing doctors, while at your appointments for you, to only prescribe approved medications, we can save you and the pharmacy (me, again) a lot of time that we can spend on more improvements to the P.A.T.H. system.
Overall, this is a win-win-win situation.  Insurers don't have to inflate their costs since they are only paying for cheaper, approved medications.  Pharmacists know the drugs are covered when prescribed and don't have to make multiple calls to offices to track down refill requests and prior authorization.  Patients have finally achieved what they have been wanting for years-Totally Hands-Off Healthcare!  They can finally say they have absolutely no personal accountability in their own healthcare (as long as the check clears each month).

Thank you for your time.  All persons interested in investing in this world-changing idea should contact me directly and we can work out the details.

*Fees and services are non-negotiable, but may be subject to change based on volume of subscriptions, street/market value of certain substances.  Previous performance is not an indicator of future anything.
   

The Death of a Profession

Pack it up, pack it in.  Call for the bugles, the bagpipes, the fiddles and the drums.  Pull out your best black dress attire and line the streets.  Sound the call to mourning and join this solemn event.  Today is the day pharmacy died.  Perhaps we can get Don McLean to sing about it.

Now this is not a "back in my day" rant for I am too young for that.  However, much has changed in the last two decades that seems to have pushed us at an incredible pace over the precipice.  Pharmacy people I say to you "We Have Lost"!

Today a pharmacist is measured by his customer service.  We've most always had a remarkable rapport with our customers.  Back when it mattered we were "the most trusted profession".  Today, in order to get a raise, a bonus, a job even, you have to hit certain customer service indices.  What makes this all the more unbearable is that people running our profession as well as our businesses are treating us like infants.

How many times have you had an irate customer who didn't understand the problem we were explaining to him, threaten to actually call your boss?, or the corporate 1-800-COMPLAINT #?, or the front end manager?  Of those times, how often did someone step in and say "the pharmacist is correct and you're a douchebag"?  In the last week alone, I have had the following customer interactions: Woman at drive-thru hands us 4 new prescriptions and asks for them to be ready at our other location (25 minutes away) in 30 minutes.  I told her we don't do that and she said "but you DO transfer prescriptions, what's the problem?"  Next we have the lady who cut all the information off her coupon except where it says ($$$Gift Card) and complained to a manager who told us to take it.  Someone whose doctor requires the patient to call for refills asked us to call then got mad when we didn't call her to tell her they denied our request (even though the office said the patient is fully aware of this because they are habitual problem patients).

Since when did we ever believe our profession would change from one of healthcare to one of service bitch?  I understand that as we have tried to do more things to help our patients (faxed requests to doctors for refills, automatic monthly refills, immunizations, consultants) we have also made everything an expectation instead of a gratuitous, professional service.  How much stuff do we give away for free in the name of customer service?  People come to us expecting us to hand everything to them.  There is no longer personal accountability when it comes to one's own healthcare.

With the transfer coupon frenzy already having sullied our profession, we have to deal with the new scourge of retail: The Entitled Customer.  He simply wants to complain to get what he thinks he deserves.  My least favourite quotes are "it pays to complain" and "the customer is always right".  When Mr. E.C. is unhappy with us as pharmacists and he complains, what happens?  Someone at the next level fields his complaint and guess what?--we get docked for poor service while he gets a letter of apology, a gift card for his trouble, the keys to the pharmacy, and the satisfaction and courage to do it again.  We are rewarding bad behaviour in the name of customer service.

It's not just my employer or my state.  This is a national problem.  I have said before, we stopped being respected when we stopped respecting ourselves.  When we had the industry at our mercy during the massive pharmacist shortages, employers begged us to work overtime, offered huge sign-on bonuses to jump ship, or to stay, this was the time to improve our lot.  Alas, that ship has sailed and we are like every other corporate business in this weakened economy--doing the work of more than one person for less money and big corporations telling us "so what?".  Their attitude is if you don't like it, leave.  We'll replace you with someone who will.

Check back next week for the ultimate business solution that will change the practice of pharmacy forever.  

Expectation vs. Reality--Redux

When do you eat dinner?  Let us suppose you make dinner reservations at a lovely bistro where they open for dinner at 5pm.  At what time do you arrive?  At what time will you have eaten?  Expectation-5pm.  Reality, depending on aperitifs and dessert and all that comes in between, 6 or 7?
Now how in the hell are you going segue this into the real world of retail pharmacy, Mr. Cynic?  Watch carefully as those creative writing classes bear fruit.  Please pause here to reread "Refill Too Soon", I'll wait.  Welcome back.  Continue.

A fine upstanding customer, usually on some type of controlled medication is told it is too soon to be filled until some day in the future.  On that bright, sunny morning, the birds are singing, the sky is clear, and a car is parked at my drive-thru.  The time: 08:35 am  Pharmacy opens at 09:00am.  As the work day dawns and the gates rise and the curtain at drive-thru lifts, the first customer of the day asks for his prescription and, after a lot of searching, is told it is not ready.  This angers Mr. First-customer-of-the-day, he who has been in line all alone for 25 minutes.  "But I was told it was too soon until today.  Why isn't it ready?"
Well, see sir, we just opened, literally.  The restaurant doesn't prepare your food before you arrive to order it and I don't process prescriptions before I arrive at my store.  Unfortunately, we had tried to train little gnomes to sneak in at night and process that day's refills between 3am and 7am, but they were not reliable.  They kept leaving little presents for us in the bottles and ate all our donuts.  Don't even get me started on what we found in the coffee pot.  Therefore, since I cannot fill anything, as in do any work until I am physically in my store and we are actually open, you need to wait.  About 20 minutes ought to do it.
Hey, what time did you wake up today to be here so early?  I see.  Did you eat breakfast before or after that?

Manners--Pay Attention

"Shut up when I'm talking to you!"  (Linkin' Park)
"Children should be seen, not heard" (Some grumpy old guy)

Both of these fittingly apply to the Pharmacist-Customer interaction.  You ask me a question.  Pause.  I answer your question, uninterrupted and you nod accordingly.  When I am done, you may follow with another question or statement, perhaps a simple "thank-you".  If you want an answer, shut up and wait for it.  If I am talking and you keep interrupting me, you are not hearing me and I'm getting quite irritated.  At this point, it would be unwise of you to ask a favor of me.
Everyone can identify with the customer who asks for a refill only for us to tell her it is too old.  While explaining that prescriptions do expire (it's like a law thing, ya' know?), you are always interrupted with "but I have to have this or I'll die!  My doctor said I'd be on it every day until I die.  I've been out of this for 3 days now (and yet here you are, undead, at my counter, dammit!)  so you need to call my doctor and get me a refill right now!".
Um, I went to school to be a pharmacist, not your Bitch!  Had you been nice (oh dear, it expired, but what is a poor little old lady to do sweetykins?), I would have gladly offered to front you a couple pills and call your doctor.  But don't expect it.  Don't demand it.  Don't threaten me either.  My favourite threat is when people say "I'm going to Derelict's Pharmacy across the street".  Good.  It's about time.  Go treat someone else like shit for a change.  However, the thing that really bothers me, is that they're like a boomerang.  They keep coming back.  Why?