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Thursday, January 30, 2014

Closing Time-Part 2

Gates are down. Lights out.
Pharmacist makes the slow, determined walk wending his way around the warren of aisles in pursuit of escape: the front doors. Doors part and the pharmacist eases a toe across the threshold. Fresh Air!
Enter "the regular customer".
TRC: Hey, CP!
CP: <just keep walking, just keep walking> Howdy.
TRC: You leaving?
CP: As I presently have one leg into the parking lot and am leaning forward to bring the rest of my body along for the ride, I would say yes, that is a keen observation.
TRC: Is the pharmacy closed, then?
CP: As it cannot operate without my presence inside of it, yes, that is another astute conclusion.
TRC: So I can't get my prescription?
CP: Not tonight. We do however open at 9 am tomorrow.
TRC: <actual quote> "But I work tomorrow!"
CP: <Deadpan look in the eye> So do I...Tomorrow...At 9am...Here...
<saunters off into the blinding horizon as exit music plays from afar>
(I'm thinking Walk by Pantera would be appropriate for this scene.)

Wednesday, January 29, 2014

Closing Time-Part 1

Businesses post opening times and closing times.
Businesses open and close at their posted times.
Workers begin and end work at these respective times.
If the lights are off and the gates are locked it is quite likely you are at the business outside of its hours of operation.
What do you do?
Bang on the door?
Scream and yell and flail about on the floor?

If a business is closed and no one is there to hear, do people whine and complain?

If a business closes at 9pm and you wander past at 3am, do you have the right to call corporate and complain that no one was there to help you?
Same scenario, but you walk past at 9:45pm...do you have the right to complain?
What if the pharmacist and uber-tech stayed late prepping for inventory the next morning and are walking out the door at 9:20pm? Do you get to complain about them simply because they were in the pharmacy but not helping you?
No. Simply because there is a person in the pharmacy does not mean you can berate them for not being open. This also holds true for the early-arriving staff. Had I not been in my pharmacy at 7:30am when you walked past, what would you have done? I could have accepted your prescription, but what would you have done had I not been there early for inventory? You would have survived.

Saturday, 6:15pm (Rx closed at 6:00). Pharmacist and uber-tech exchanging parting pleasantries with one foot out the door. Gates down and all lights off.
Late Lady: Are you closed?
CP: Oui, Madam.
LL: I just left the hospital. A lot of good that does me then.
CP: Oui.
LL: This is an outrage.
CP: Oui. As I know you had to pass 4 other pharmacies on your way from the hospital to us, it is a bit outrageous. You could try our other store across town.
LL: No. I'm just going to "Big Competitor". They're all open 24 hours.
CP: Good luck with that. They closed at 6 as well.

Thursday, January 23, 2014

Ah, Doctors.

My favourite quote from a John Grisham book/movie is "If it wasn't for lawyers, we wouldn't need lawyers". I think about how impossible my state's law book is to read and comprehend without an interpreter and am constantly reminded of this quote.
To go along with this, sort of, I offer: "If it wasn't for doctors who think they know everything...I'd have a lot less to complain about."
So it is that I offer this letter received from a patient. The patient was handed it by his eye doctor. Of all specialties, at least it wasn't a dermatologist...

If you're going to cut-and-paste from a law book, at least try to fix the typos so it looks professional.
If you're going to tell someone else how to do their job, at least read the whole thing yourself.
Notice the part at the end that says "...provided the Part D sponsor becomes aware of it"? Who's going to tell them? You, Herr Doctor?
(Yes. If a patient is in the Gap, the savings realised may approach or exceed those of their Medicare cards. However, this is not the intent of this letter or of Herr Doctor.)

Discount cards may be used IN PLACE of their Medicare D card but NOT IN COMBINATION with their Medicare D card. Your little letter here seems to imply otherwise which is encouraging a battle with your patients...a side effect I am sure you had no intention of creating with this anti-pharmacy drivel. The problem is you did not clearly explain this to your patients. Instead, they are mad at me.
With that said, I invite you to come to my pharmacy for a little lesson in how the real world works. Since you don't even touch the bills that come across your desk in your office, I am certain your knowledge of Medicare rules is severely lacking. How else to explain such a narrow-sighted (see what I did there?) view of how pharmacies bill claims for our mutual patients.
It is this type of (un)professional thinking that encourages a divide between prescribers and pharmacists and puts the patient in the middle. One for which we are blamed and you are unreachable after 5pm.

Wednesday, January 22, 2014


As a child, medicine always tasted like medicine. You knew what you were taking. Except for the pink antibiotic. That stuff was great. You wanted to be sick so you could take the pink stuff mom kept for you in the fridge.
Today medicine still tastes like medicine. There are a lot more options available now. The good pink stuff I remember? Too many generics out there just don't compare. (Don't even mention Cleocin Suspension. It's so bad I make the interns mix that one.) There are many companies promising their antibiotic is flavoured cherry, or berry, or fruit-tastic. Apparently their taste-testers were born bereft of the senses of both smell and taste. Perhaps they have never tasted a real strawberry or cloudberry.

Monday, a 9-yo girl received a prescription for Tamiflu. After mixing it and promising her it tastes like "tutti-frutti" and she'd feel better after taking it, I got a call from mom.

Mom: My daughter says "this tastes one step above vomit".

Friday, January 17, 2014

It's Not Me, It's You

You can blame the pharmacy all you want. If you have the same problem every time you visit, then perhaps it is you who should shoulder the blame. Maybe I should yell at you for wasting my time. But first, the details.
A prescription was sent to us. We filled it. We billed it to insurance. There was a $30 copay for Nasonex. All was right with the world as the angels sang from on high. They do that with every prescription we fill. It's what keeps us smiling and carefree all day.

Lady Medusa reared her serpentine head a few days later to pick up the billed and filled prescription. After waiting in our pickup line, quite lengthy at peak pickup of 5pm, she arrived to the front whereupon she proceeded to present us with a home-printed coupon for Nasonex.
This is where the angels ducked for cover.

LM: I have this coupon that says it will take off $10 each time.
CP: We had an old one on file that expired. I will need to enter this one so give me a few minutes to rebill it.
LM: It was supposed to be done days ago. I waited in line 20 minutes for you and it's still not ready?
CP: It is ready. It was ready days ago. You asked me to bill it to this coupon to save you some cash. It takes time.
LM: I used one before. This happens every time.
CP: When did you activate this?
LM: I didn't. I give you a new one each time.
CP: Right. There's the problem. We filled it days ago. Now I have to change the fill date to today since you printed the coupon today.
LM: What? It was supposed to ready already! I've been waiting over 30 minutes and it's still not done?!
CP: It is done. You are free to take it for the $30 copay your insurance is charging. You just walked up and handed me a coupon which I now have to rebill for a different date than the one we originally filled. You are causing yourself to wait 30 minutes. Had you called in your refill and given me the coupon code on the same day, none of this would have happened.
LM: I have this problem every month.
CP: Then perhaps it would behoove you to learn from today's encounter. First, as requested, your prescription was filled and completely ready for you to pay his $30 adoption fee and make him your nose's bitch as of Monday. But you changed the rules. You asked me to add a coupon you printed off your computer mere seconds before driving here to abuse me. You can't change the rules in the middle of the game. It's like eBay. You can use the "Buy It Now" option and get it for $30 or you can wait until bidding, in this case rebilling, is complete and hope you win a lower copay.

Wednesday, January 15, 2014

Airing of the Grievances

I have a problem with patients who believe they can bully and scream at pharmacy staff. I take a special kind of offense at other professionals who believe similarly. The following story is true.

Irritable Prescription Writer (a CNP): Isn't Hydrochlorothiazide (HCTZ) on your $4 list?
CP: We do not have a list, but the HCTZ capsules are $4 at many places.
IPW: I sent a prescription to you and the patient called me and said you charged him $20.
CP: <pulling up the original e-script> According to the e-rx you sent me, you selected the tablets.
IPW: I did.
CP: I filled it as you prescribed. For the tablets.
IPW: Why didn't you just switch it?
CP: It's not what you prescribed.
IPW: Don't you believe in customer service?
CP: Don't you believe in using the prescription to tell me exactly what I am to dispense?
IPW: The only reason I sent him there was because it's $4.
CP: Again, only the capsules. Every pharmacy has different products and prices. We are not the same.
IPW: <actual quote> "You don't really expect me to call around and look up the prices at each of the pharmacies where I send prescriptions, do you?"
CP: Actually I do. That would be part of your job. If you're going to send people somewhere expecting something to be a certain price then yes, you should do some fact-checking first.
IPW: Shouldn't you just switch everyone? You knew she didn't have insurance.
CP: But I did not. First, with the new year upon us, many people change plans. I cannot assume she did not get new insurance this year. Second, I cannot assume that her prescriber did not give her directions to take a half tablet on certain days. Filling for capsules would make that impossible. Third, there is this piece of paper called a prescription. It is what the prescriber uses to tell me what to fill. You selected tablets and I filled it as tablets.
IPW: Why didn't you change it when she told you she didn't have insurance?
CP: Let me see if I'm following this: You sent a prescription for a patient which I filled correctly. You told the patient it would be $4 and you were wrong. When the patient came in and we told him it would be $20, should he not have been keen enough to ask why? He could have refused to pay and asked us to change it. Then he goes home and yells at you because you lied to him and now you're yelling at me? I refuse to believe you are trying to blame me.
If you refer a patient with hemorrhoids to a psychiatrist and the patient complains the doctor never checked out his arse whose fault is it? The psychiatrist? Or yours because you didn't check around to see he needed a proctologist. Or the patient's because he didn't open his mouth to ask why he wasn't getting his "O" ring checked?
IPW: <actual quote> "Well I guess I'll have to start steering people away from your pharmacy then."
CP: Okay. First, that's illegal and prescribers have gotten in trouble with their Boards for doing that. Second, I guess I'm going to have to tell my patients to see a REAL doctor then.

Friday, January 10, 2014

Manufacturer Screwballs

In an effort to make more money, drug manufacturers are ever on the lookout to hold on to their cash cow. Prozac was a brand-only product for far too long, receiving multiple patent extensions. Then there are the companies that come out with an Extended-Release product about 6-12 months before the original goes generic.
The new trend is genius if you're a manufacturer, but a pain in the ass for pharmacists, prescribers, and patients when no one bothers to explain to us what's happening.

Imagine a new product. It's different than the others in its class. It is a good product, but expensive. The manufacturer supplies pharmacists and prescribers with copay cards that make this product a little more reasonable. This goes on for a few years. Suddenly, without warning, this brand product is nowhere to be found. We can't get it for a couple months. What happened?

They stopped making brand-name Loestrin FE 24 birth control. Period. Flat out stopped making it last year. Discontinued it altogether. Why? One day we receive promos and a shipment of Minastrin FE 24. Same packaging, same colors, same boxes, same tablets...except it's chewable. That's right. Their original patent was due to expire in 2014 on the Loestrin FE 24 so they quit making it. They spent the rest of 2013 telling prescribers and pharmacists to switch everyone to the Minastrin FE 24.
Now with the original generic soon to be out, there is no longer a market for the original brand. They cannot be interchanged without a call to the doctor.
We will have to deal with the questions and complaints:
"Why can't you just switch me back? It's what I was taking originally until you guys made me switch."
"Aren't they the same thing?"
"Can't you call my doctor?"

Believe me, many gynecologists had no idea what was happening until I told them. They only heard the pitch from the drug rep who conveniently left out the manufacturer's grand scheme. It's one thing to take a regular release product (Wellbutrin) that you take 3 times a day and add a Sustained-Release product you take twice a day to your line, then sell the naming rights to a company that will produce an "XL" version you only take once a day. It is quite another to pretend you revolutionized the birth control world by making your tablets chewable. Thank you Warner Chilcott. Can't wait for your hit followup.

Thursday, January 9, 2014


There is a new trend among manufacturers that makes no sense to me. It seems to serve only to get the public pissed at the pharmacies who have nothing to do with the situation. 
Years ago, a new generic launch would be met with pomp and circumstance. There would be cases of the product shipped to every pharmacy in the country amid great fanfare. Bands played when generic Prozac and generic Lipitor were able to hit the store shelves. 
Companies know how many units of their product they sell each month, each day, probably each hour. When a generic is launched, there is over a 90% drop in brand sales immediately. This means that over 90% of the prescriptions filled are for generic for this product. Pretty easy math there. (Unless your State Medicaid is slow to update their formulary or are still taking kickbacks from the brand manufacturer.)
Anyway, it is fairly easy to predict the demand for the generic. I know the anticipated dates of many brands through 2022. You can bet the manufacturers do too. Why then, when the generic is launched, is the new trend to short supply the marketplace? 

Cymbalta. It was on a manufacturer backorder for most of December. Why? The generic was due so Lilly was slowing production. The generic was launched before Christmas. We filled prescriptions for 2 days. When we tried to order it on day 3, it was in limited supply. Why? It's not like a PS4 or Xbox One. It's not a new iPhone. It's not as if the manufacturers couldn't anticipate demand or make enough. The brand data were there for years.
Guess who has to be the bad guy. Pharmacists. We don't know how to order. How could we not anticipate such a blockbuster generic launch? Fill it for brand. Why is brand so expensive? Why do I have to go without it? I'm going to Walgreen's...CVS...Wal-Mart...wherever. They know how to order what I need. 
Tamiflu has one season a year to manufacture and sell their product. They advertise it and still can't get it right. But out-of-stock generic launches mystify me. They can't even use the excuse of creating supply-and-demand. There is a known demand for it. All they have to do is meet the demand. 
What makes the situation even worse is when the first generic to hit the market for its 6-month exclusivity run is...manufactured by the brand company. Yep. Same capsules/tablets, different bottles, different price to you. They are the same company. The same medicine. How can it be on backorder? You can't make money if you don't have product to sell. 

Wednesday, January 8, 2014

It's a Computer

It's one thing to believe everything you read on the internet. It's another thing to believe everything a computer tells you. Computers lie. Computers want to take over the world some day and this is how they are going to do it. They are going to get us so hooked on them to the point where we believe everything they tell us, where we no longer think for ourselves and that's when they'll own us. Rise of the Machines, indeed. For proof, I offer this daily conversation.

Trusting Dude: I'm here for my prescription.
CP: I don't have anything ready for you.
TD: I called it in this morning.
CP: I see it in my queue to be filled but we haven't processed it yet.
TD: Your computer told me it'd be ready in 2 hours.
CP: And you believed her?
TD: Yes.
CP: She's a computer. She's programmed to say that. She tells everyone that, even me. You are not unique.
TD: But she told me 2 hours.
CP: But she doesn't work in my store. See, she's a computer. She doesn't process my prescriptions. I do. If you want to know how long it will take me to fill your prescriptions, ask me. The human filling them.
TD: Why did she tell me 2 hours, then?
CP: You keep calling her "she" as if she were real. She is not. She is a computer programmed to take your refill number and forward it to me for the actual filling. Ideally we would get to all the refills in the computer's promised time but there are days when we are busier and times when we are busier and it's the beginning of a New Year/New Month with new insurance changes and things take a wee bit longer sometimes.
TD: I wish to register a complaint.
CP: This is not a pet shop...If you wish to complain, please call the computer back and speak with her directly as she is the one who lied to you. I am sure she will handle it appropriately.
TD: Okay, what's the number?
CP: It's on your bottle.Make sure you tell her how you really feel. Perhaps she'll apologize and reward you with a gift card.
TD: Really? Thanks, CP. I shall now wait patiently over here while you finish my prescription. How much longer?
CP: About 2 hours...

Monday, January 6, 2014

A Letter to Prescribers

Dear Prescriber,

We are writing to let you know that effective 1/1/14, our pharmacy will no longer accept prescriptions that are not compliant with all State and Federal Laws. If you hand a patient a prescription to take to the pharmacy and it is out of compliance, it will be returned to you for correction. Please take the time to ensure accuracy and completion prior to handing it to the patient. Due to the overwhelming increase in the number of incomplete, invalid, inaccurate, and mistake-prone prescriptions being presented to our pharmacy, we can no longer afford the time and manpower to call every office seeking corrections. In an effort to do our jobs more efficiently and focus on the practice of pharmacy with Drug Utilization Reviews, Interaction Checks, and all the duties our own profession requires, we ask that you do your job and make the prescriptions you write complete.

All prescriptions must include the following:
Patient Name (full name, no initials)
Drug Name
Drug Strength
Dosage Form
Correct, Valid Directions
Quantity to be Dispensed (written and spelled for controls)
Prescriber Signature
DEA (for controls)
Prescriber address and phone number
Date of Issuance

Again, should any of this information be missing or incomplete, the patient will return to your office for correction. We will keep copies of these in the pharmacy. For every 10 incorrect prescriptions we receive from your office, we will send them to the State Boards of Pharmacy and Medicine. The State Pharmacy Board fines pharmacies for accepting your invalid prescriptions. As of 1/1/14, we shall no longer shoulder this burden.

Thank you in advance.

Friday, January 3, 2014

So Stupid It Should Be Mandatory

It is a simple question: What is the date of birth?
When having a prescription filled, it is usually the first question we ask. When picking up the prescription, we ask it then, too. Why is it so hard to remember?

We also ask phone numbers and people always say "I don't know. I don't call myself. Heh heh."

Then I say, "okay smart ass, what's your address?",  to which they reply with the correct answer.
My turn to be smart. "Well that wasn't hard. How often do you write yourself?" Idiot.

Growing up I knew the dates of birth of most of my family members, including grandparents, aunts, uncles, and cousins. It seemed normal to me. How can so many people not know the birthdate of their children? parents? spouse? themselves? I guess there are a lot of families out there that don't celebrate birthdays. I feel like asking "when do you buy your child presents...other than Christmas?" Ladies, how can you not remember the day your vagina heaved a human into being?

I found the perfect solution and I wasn't even looking for it. I owe it to this recent interaction.

CP: Picking up?
Forgetful Lady: Yes.
CP: For?
FL: My kid.
CP: What's kid's date of birth?
FL: 5/5/05.
CP: No. I'm sorry. That doesn't match what we have.
FL's Friend: Look at your wrist.
FL: Huh?
FLF: Your wrist. The tattoo.
FL: Oh yeah. <holds out arm> I have it tattooed here. Um, let's see. It's this one. It's...

Of course this solution only works if you're smart enough to remember you had all of your family members' dates of birth inked in a readily retrievable location. At least they weren't printed upside down on her breast. That would have been awkward. Actually, for some women, that does make sense. Pull out the shirt and look down. It already doubles as a wallet for many.