Facebook and Twitter

and follow my blog on Twitter @pharmacynic to receive notifications on new posts.

Tuesday, April 19, 2011

Transfer Coupons

Let's just say that these piss me right the hell off.  Pardon my English, but I don't speak French.  Where else, in a professional world, can you do business where your life is at stake and, oh yeah, could you take my coupon, please?  When was the last time you needed heart surgery, called around for the lowest price, and asked Dr. Zoffis "thanks for the cheap price, can I also get a $25 gift card since I picked you?"  Some things should just be illegal and I thought State Boards were in place to look out for everyone's best interest.  Apparently I was wrong.  See, the State of Ohio has a Board that has no balls.  I don't mean it's emasculated, I mean it's a giant eunuch.  Our law book is the size of a set of encyclopedias, A-Z.  In it are all the things we as pharmacists cannot do.  It takes two pages to describe what a prescription is.  To say it is verbose does not do wordiness justice.  I need a lawyer to translate it to me.  Anyway, the rules have never been about pharmacists; they've always deferred to customers first.  While there are many rules on the books that have been beneficial, the one enacted January 1, 2011 limiting patients to one transfer per prescription was their best yet.  Unfortunately, since our state Board sees pharmacy as no longer a profession but a business, they are in the process of reversing this rule.  Ohio's Board has received a number of complaints over the years from pharmacists that coupons are a problem and the Board needed to take a stand.  After many years, the best they could do was limiting transfers to one time.  What a way to take a stand without actually committing to something.  It was precisely this thinking that has allowed them to back away from this rule now without saying they were wrong, or right.  They have retreated under consumer pressure.  The arguments against the rule were basically anti-competition and inconvenience.  Boo-f-ing-hoo.
We're not talking about the lowest price on an iPod or a 2-for-1 deal on Cheerios here.  Patients are using their medicines to make money.  Period.  Anti-competition?  Bullshit.  In NY and NJ, coupons are outlawed, explicitly.  You cannot incentivize using prescriptions.  In one of my stores, 5% of my weekly total was transferred either in or out for nearly a year.  As a solo pharmacist, that's a lot of extra work spent on the phone just so some guy can use his mom's 14 medications to get $25 from every retail outlet in the city.  People admit they're only coming to us for the coupons.  The retention rate on coupons is around 20%.  How about I get some extra help so I can provide better service so people will enjoy coming to me as a pharmacist instead of the dirty little whore that you've made me?
 The media and the Board of course disagree with me.  The original reason the Board gave for ushering in the new rule was patient safety: the more you transfer a prescription, the higher the risk of an error.  Exactly, just like the old telephone game you played as kids.  Only with medicine that affects people's lives.  Bollocks!
What exactly caused all of this to go so wickedly out of control?  Was it a single competitor trying to establish market-share or a foothold in a new area?  Was it one of those "seemed like a good idea at the time" situations?  I know for a fact that one company, when asked why they were in the coupon business, said "everyone else is doing it and we need a chip to play at the same table".  Comforting.  No one is willing to take a stand on this issue, not the pharmacies, not the Board, not any government agency.  Why?  If other states can outlaw coupons, why can't Ohio?  A previous blog entry noted that "that Harrisburg-based company" now has a 15-minute guarantee and advertises they have your health and wellness as their top priority.  How is this true?  Pharmacies cannot have this as a top priority, nor can the Ohio Board if they continue to push pharmacy toward the brink.  Pharmacists are overworked, understaffed, and expected to undertake other projects to meet business goals.  I get it.  It is a business.  But it is a healthcare business.  We need to actually act like we care instead of saying it out one side of our mouths while telling people to bring us a coupon out the other side.

Friday, April 8, 2011

The 15-Minute Guarantee

It is official.  The profession of pharmacy has finally succeeded in minimizing the profession part of our jobs in exchange for rebranding ourselves as an oil change place.  It's like trying to outdo the 9-minute ab workout by creating an 8-minute ab workout.  At an oil change place, all they do is pull a plug, let it drain, then fill it with new oil.  This is exactly like pharmacy; you bring us something empty and we just put pills in a bottle, right?

The way the system is supposed to work is the prescription is entered immediately at drop-off.  With usually one computer located here, this means everyone will now be waiting in line to drop off instead of waiting for it to be filled (and the clock doesn't start while you still hold your Rx).  It's like a shell game where you move something without the audience catching you.  Like everything else, the devil lurks in the details--only 3 Rx's, excludes Rx's needing ordered, prior authorizations, contacting your doctor, calling insurances, etc.  Hell, anymore I have to contact doctors because they still haven't learned how to write a correct prescription.  (I just had two separate doctors send in scripts with a control and non-control on the same blank in two hours and one was clearly marked "not for controls".)  Anyway, I cannot wait for people to come into my pharmacy and say they want it in 15 minutes.  We usually average 20-25 minutes during even peak busy times, but I also have to deal with technician call-offs, peak business before and after holidays, the full moon syndrome, big storms, and radiation fears, etc.  On top of all of this, what happens when we catch a mistake or serious interaction?  The same thing that happened when, despite being on the market for nearly 20 years and always prescribed as 5ml BID, I received a Tussionex script written TID-QID.  Called the doctor and got yelled at by the patient that he had to wait because my job was just to fill whatever his doctor wrote.  Yep, and now I have to do it in 15 minutes if I work at that Harrisburg-based company?  NO thanks.  Now would this then nullify the guarantee?  Do you think in this relatively minor case the patient would understand or care?  Do you think he'll bitch enough about the inconvenience and the only reason he went there was for the "guarantee" and he'll end up getting a gift card anyway?

With all the work we have to do, do we really need to add a layer of stress over every Rx we fill that if we don't meet the guarantee it'll cost me $5?  What happened to us?  What's next, pharmacy staff getting docked pay/raises/bonuses because they had too many waits over 15 minutes and had to give too many $5 gift cards?  Trust me, they can and do track that sort of thing over there.  I believe in a better solution, pharmacy world.  I believe we can hire a fairly qualified technician at $10 an hour.  This would keep us going faster and provide the assistance needed to get everything done that we need.  That's the equivalent of only two(2) missed "guarantees" an hour.  I think most pharmacists I know would much rather have an extra body in the pharmacy to lower stress than to have to meet a guarantee with fewer people and much higher stress.

The funny thing is, in the promotional ads for the guarantee, they explicitly say "we care about your health and wellness".  Really?  How can you claim that?  That's like saying I care about your weight, go sit in my waiting area and enjoy the free Diet Coke and donuts I set out for you.  Just like McDonald's is a health food store, right?

If they really cared about these things, they'd hire better tech help, make it easier to hire and fire based on job performance, pay them better, and just give pharmacists the help they need.  They, like many other competitors, issue coupons for gift cards with the transfer of a script.  This brings in a short-term bump in business, but not a long-term growth solution.  Inconceivably, they of course do not schedule accordingly for these bumps.  Add these coupons to understaffing and a guarantee and it's simply a recipe for disaster.  And with the high cost of health care to work there, the least they could do is provide free blood pressure medications to its staff.

Simply put, we are just whores.  The oldest profession in the world.  When we stopped respecting ourselves, we stopped being respected.

Tuesday, April 5, 2011

Electronic Prescribing-Savior?

E-Rx's, or as I  prefer to call them- The new scourge of healthcare.
Let's introduce the newest tool used by prescribers to shirk some of their human responsibilities when it comes to writing prescriptions for their patients.  Pharmacists are already used to deciphering the hieroglyphics doctors use hand writing scripts in felt-tip or other ink.  It has become like a second language to us and our staffs.  Our technicians already come to us to ask for a second or third opinion on what the Rx actually says, or who even wrote it.  Add poor penmanship to the ghastly custom of doctors using cell phones to leave us voice mails where they leave the office number, but not their cell number and we should be paid as detectives as well.  Mix this with nurses who spend a large part of their time calling Rx's in to pharmacies but can never quite manage to get all of the details covered in one call and we now have to call them back to research all of this for us.  When we call to get this info, why can they not remember each subsequent time, that this is important and if they do not leave it, we will have to call them back thereby wasting everyone's time?  It's simple, formulaic even: "HI! This is Barb (there's one at every office) from Dr. Zoffis calling in a script for Sandy Cheeks, DOB 5/5/75.  She needs Prozac 20mg, once a day.  Give her 30 with no refills.  Our phone # is..."  If you're really spot on, you'll remember the DEA on the controls too.  Since I am an equal opportunity cynic, I must say it does go both ways.  When we call for refills, we need to slow down and enunciate our info.  I don't like people calling us back saying they didn't know what the patient needed, who the patient was, or even who we were.  
Another thing I can't understand is the office person calling and telling us to "just refill what they had last time.  You have it on file".  Yes, I do have it on file.  So do you.  In that thing in your office called a chart. That you keep on every patient.  Go get it.  Read it to me.  I'm not paid to be your file clerk.  Just because the girl who answers your phones took the message from the patient as "hydradyzine" or some other combination of what they think they are taking doesn't necessarily mean it is correct.  Here's your opportunity to do your job and fix it.  There's a good chance the doctor may have changed something; or the patient requested 90-day supplies on everything now; or he just switched pharmacies because he has a coupon and we've never filled that for him; or he has a new allergy; or someone misfilled it last time and this is your chance to catch it.  This goes with the patient who calls for a refill and the office calls us and says "well, he hasn't been seen for over a year.  Go ahead and give him a month with 11 refills and tell him to make an appointment."  Fine.  I understand I'll see him before you will but what kind of incentive is there for him to make and keep an appointment if you don't bother making him visit you but every couple years?  You even put these notes on your E-Rx's.
On top of everything else you ignored so far and you have us doing for you, I have to schedule your appointments and, in the electronic prescribing realm, this is the part you care to take the time to get right?  I was skeptically hopeful this would help our profession provide better service to our patients when I saw this software is so easy, even a caveman (or elder statesman physician) can do it.  It appears a lot of these offices have employed this caveman as their IT guy too.  Instead of a doctor making a mistake by writing illegibly or attaching the wrong strength to the wrong drug (Nexium 30mg), I believe the mistakes made on E-Rx's can be even more egregious.  It's a lot like the auto-correction function on your texting keyboard.  What often appears may seem similar to what you intended, but makes no sense on the whole.  I'm not talking about selecting Amoxil CAPS vs. TABS, but scripts that read like a giant non sequitur.  For example: KCL 20 mEq SOLN, #30 1 tab qd; or Lorazepam 1mg soln (as either injection or intensol soln) qty #30 and to give 1 mg sublingually.  On these examples, after some research the doctors actually wanted KCL PACKETS and Lorazepam 1mg TABS to be administered SL.  How many different ways could a pharmacy have filled this?  This ultimately comes from not checking what was selected from the drop-down menu.The next line on many of these is the quantity.  While often omitted on handwritten scripts, it is more common to see "N/A" in the quantity field than an actual number.  This should never be skipped, ever.  How about those directions?  How many times have I seen "1 tab(s) 3 qhs"?  This would obviously not happen on a handwritten script and I can read this version, but what does it mean?  I mean, it's like the doctor is trying to speak to me, as if his lips are moving and words are coming out, but I'm missing the key to the mystery.  
I have no confidence in an office that will let these scripts leave in their patients' hands without being double-checked.  If they are being sent to my computer or fax, that is a different story, but isn't there a hard-stop that asks "are you sure?" before it is sent?  The worst is when I call the office, just doing my job by clarifying, and the nurse says "oh yeah. they told us that could happen all the time.  We can't figure it out.  It just happens."  Seriously?  Your answer is "WTF"?  I can tell you exactly why it happens: YOU are NOT paying attention.  No one is.  Except for me.  It's just click-and-tap-and-print-and-send.  What's happening is the same person is doing the same thing and not fixing the problem.  If you always do what you've always done, you'll always get what you always got.  Just wait until it gets to a pharmacy that's too busy, that carries that odd drug you prescribed that makes sense to them, and they don't call but fill it as-is.  
Alas, as I originally feared, this has not become our savior, but yet another issue for me to have to overcome in my daily routine of "everyone else's problems I need to fix".