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Monday, September 29, 2014

Fast Cash

Thanks to Corporate Greed, what should have been viewed as a worthwhile service, an important function of our jobs, has been relegated to the "you want fries with that?" suggestive sell.
Flu shots are important.
Getting one is important.
Waiting for 15 to 20 minutes to get one? Not so much...

I came up with a plan to deal with this scenario I had over the weekend.

Impatient Lady: I want a flu shot.
CP: Certainly. That will help me reach my quota. Please simply fill out this important, required questionnaire and I will process it for you.
IL: How long?
CP: About 20 minutes from start to stick.
IL: <throws paper and pen back> What? I want it now! Why do I have to wait? I'm going somewhere else.
CP: Okay, Veruca Salt. You do realize that the next closest pharmacy is a 20 minute drive, right? Plus you have to storm out of here, walk to your car, drive there, park there, go in there, wait in line there AND be told it'll be 20 minutes, right? Just making sure you have thoroughly thought through your hasty decision.
IL: <storms off>

It was then that I decided to revisit my Disney FastPass post from last year.
What if we offered "instant flu shots"? No waiting?
I don't mean a flu clinic where people still have to wait in line. (We used to have clinics where people would ask how long. I averaged 3 minutes per shot if all the paperwork was completed. Sorry, but the 20th person in line? He has an hour wait.)

I mean instant, shoot-em-up now flu shots.

IL: I want a flu shot.
CP: Certainly.
IL: How long?
CP: 20 minutes.
IL: What?! I can't wait that long. I have ice cream in the car with my baby who is on his way to the airport to fly to a dentist appointment for which he needs an antibiotic filled at another pharmacy one hour beforehand and the appointment is in 30 minutes.
CP: Wow. Well in that case, I have an alternative for you.
IL: What's that?
CP: Instant flu shot.
IL: Yes. Yes. I'll take it! How's it work?
CP: I walk with you into that little room over there, grab my syringe I pre filled this morning, and as I am helping you fill out the questionnaire, I am prepping you for the shot. I do all the hard work so you don't have to wait.
IL: I like this. Let's go.
CP: One catch.
IL: What's that?
CP: It costs $60.00
IL: What? All pharmacies are charging less than $30.00 for their flu shots.
CP: I know. But they are also making you wait...and wait...and wait...and fill out your own paperwork. Then they are billing your insurance. I am offering you a reasonable solution to your self-inflicted problem of poor time management. Your choice is simple: Wait 20 minutes or pay for the expedited, Platinum Club service. Maybe I'll even let you pick out your own BandAid...for free!

Friday, September 26, 2014

Phone Menus

Having to dial different pharmacies, insurance companies, prescriber offices, and takeout places can make one a so-called expert on phone menus. I like the ones that tell you "please listen to the message in its entirety: our options have changed".
When was the last time you updated that message? Your options haven't changed in years.
I think if you're going to change them, change them frequently. Also, make the options erratic and senseless. People will have to actually listen to them instead of getting menu fatigue. Change the options every week. If patients had to press 369 to request refills at your office, change it to 17 the next week and make 369 an automatic disconnect.
Will they call the pharmacy? Absolutely!
Will the ask us to call the office for them? Of course.

If you are from a prescriber's office, press 9999999999999999999999999999999999999.
If you wish to speak to a member of our pharmacy staff, press the square root of 4, cubed.
If you wish to call in a refill and have your rx#, press 1138.
If you wish to call in a refill and do NOT have your rx#, please hang up, go find your bottle, and call back.
If you are not sure what pharmacy you dialed, please press "end" on your phone and call back to listen to the greeting again.

A Letter to Corporate

Dear Corporate Pharmacy,

I would like to thank you for my gainful employment and the paychecks that come with it. It has been a great career so far and I have seen many changes that have improved our profession. Along with these positive changes, I have also witnessed the ruination of the profession I love. I lay the blame squarely at your feet, corporate rulers.
It is unfortunate that you seem so out of touch with what our profession represents. It is time you rethink your policies and procedures and hiring practices. It is time to take off your suits, walk into our stores, put on a lab coat, and do the job you wish to destroy; the job you think you know. While you are there, you can take a few pharmacists and technicians and move them into corporate offices so they can write the new P&P manuals. They can dictate how a pharmacy should work. More importantly, you need to STOP making policies and procedures and just let us do our jobs without interference.

Let me provide you an example.
Most pharmacies have two cash registers and many have a drive-thru. If I have one technician for the register and one to perform data entry, then no one is counting. If a line builds, people will wait and become irritated. They will complain. We at the store will get docked for poor customer service because we are not quick enough. However, we are working within the budget sent to us by corporate. Imagine a Superstore with 30 checkout lanes...after Thanksgiving. What is the best impression for customer service? A. Customers walk in and see 30 open lanes with 30 cashiers and only 5 people in each lane, or B. Customers see 30 open lanes, only 1 cashier working, and 150 people waiting in that one lane? This is what you have done to pharmacy.

I have always been in favour of pharmacists providing immunizations. I am on board with MTMs. What I have a problem with is continuing to add tasks to our daily responsibilities while not adding compensation or support for the increased workload. Have you read Animal Farm? You have made us Boxer ("I will work harder"), while you have become the pigs.

Thursday, September 25, 2014

We Just Can't Win

I realise it has only been 9 short months since the changes were made to all Hydrocodone/APAP products that limited them to containing no more than 325mg of Acetaminophen.
I realise doctors can't learn anything new such as drug/strength combinations that have been around for a long time. (This is actually OUR fault. We always call and fix it for them. But I digress...)

Doctor wrote a prescription for Vicodin 5/325. Since we are not allowed to assume which part is correct, we are required to call.
CP: Which did you want? The VICODIN name which is 5/300 or the NORCO which is 5/325?
Dr. I Can't Know New Things: I wanted the 5/300.
CP: Super-dee-duper. Thank you kindly.

As I process it, the insurance rejects as a non-formulary, non-preferred drug. Great.

CP: I need to get this changed to the 5/325.
DICKN'T: Why didn't you tell me that before?
CP: I don't know formularies and copays until I run it. Since I did not, at the time of my initial phone call, have a valid Rx to run to the insurance, I was not privy to that information. Besides, who are you to talk? You didn't even know the correct drug/strength combination you prescribed. After 9 months you should have been able to figure that out by now. Women grow and birth babies in less time than it takes you to learn how to write a prescription...which is your actual job.

Wednesday, September 24, 2014

One Bottle Does Not Equal One Bottle

I know this will seem far-fetched but I got into an argument with a doctor over an error on her e-rx.
If she had only taken my phone call instead of relying on the phone tree to answer my question this would have been an easy fix. Instead I had to resort to telling the secretary who yelled, often incorrectly, to the nurse in the background who yelled to the doctor who yelled back to the nurse, back to the receptionist then into my ear.

Here was the problem: Rx was written for Zyrtec Syrup. Dispense one bottle.
Great. We get this in pints because Medicaid covers it. I'm pretty sure she did not want to give the patient a pint. I asked for clarification on the definition of "one bottle".

Doctor Obvious: I wrote for one bottle. Just give them one bottle.
CP: Bottles come in different sizes. We get pints. This bottle would last for 96 days at your current directions. Is this really what you want?
DO: I want just one bottle.
CP: I can give the patient anywhere from a 1 oz bottle up to a 16 ounce bottle. You have to pick one.
DO: Why are you making this so difficult? Just give one bottle.
CP: Why can't you figure out how to use your e-script software and select a quantity? If you wrote for Hydrochlorothiazide 25mg tablets to dispense "one bottle" would you expect me to just give them my 1000 count stock bottle?
DO: That's different. (actual quote)
CP: HOW? How is that any different?
DO: We've had problems with you before.
CP: Go ahead and say it. I know it's coming...
DO: (and CP, in head) You're the only pharmacist that ever calls on this, blah, blah, blah.
CP: Yep. I guess I like my license. Tell you what. Figure out how to use your software or the next e-rx that comes over like this will just get sent to the Medical and Pharmacy Boards.
DO: 4 ounces! <click>

Yet in everyone's eyes, I was being the asshole. All she had to do was give me a quantity. That would be the same as her writing an Antibiotic Rx for 10ml twice a day, dispense QS without the duration. I would still have to call...and she would probably tell me "one bottle!" without understanding what she did wrong.
It is our job to fix your problems.
It is our job to fix your errors.
It is our job to save your ass.
I'm not asking for a "thank you".
Just don't go all "Vicious Twat" on me.

Tuesday, September 23, 2014

It Says Consultation

Sign, sign, everywhere a sign...do this, don't do that, can't you read the sign?

No. People cannot read them. If they can, they choose not to read them. It is far easier to interrupt someone than to look for something on your own. With that being said, it is quite obvious there is no patience anymore. We are a harried, hurried lot. Protocols and decorum are not meant to be followed.
Lines at businesses are just a suggestion. If you wish to push your way ahead of other people for what you feel is a simple question, then you march your ass right to the front and ask away.

Most pharmacies have designated points, yes, marked with signs, that guide people to:
A. Drop-off,
B. Pick-up,
C. Consultation.

I believe the most common design flaw with this is that the Consultation Window is often too near the pharmacist or another workstation. This invites the Everyday Patient to stroll on up to the window, lean across the counter, and bellow "I just have  a question".
I am certain you do. That is the point of this point of access. Questions. Consultations. However, it does not mean stick your head in my window or sit on my counter and start talking to me as if I am Santa and the counter is my lap. I am on the phone. I am checking prescriptions. If it were your phone call or your prescriptions, would you not want me to be focused solely on you?

It's like walking into a bank, seeing a line of customers, then strolling to the front right next to the first person and saying "I just have a question". That's not how it works.

I think we need to redesign these areas. My first thought is that they need to be on a separate wall of the pharmacy, a wall which a pharmacist will need to move to in order to provide counseling. My second thought is that we should have a glass partition with a speaker. We could set it up like a movie theatre ticket booth or a prison visitation centre. The pharmacist would have to turn on the microphone, or pick up the phone and the patient would talk into the speaker or the phone on his side. Brilliant!


Monday, September 22, 2014

I Was on Hold For...

All professions are not created equal. We each have our own expectations for ourselves and for the other professions with which we deal. Sometimes those expectations are rather unrealistic.

Uber-Tech: Thank you for calling CP's Pharmacy. How may I help you.
Irrational Rx Expectation Deliverer: I need to call in a prescription.
UT: Can you hold, please? CP is on the other line.
IRED: Sure.
(some time later...seconds, minutes, hours, days...)

UT: Thank you for calling...
IRED: I need to speak with the pharmacist. I just called and was left on hold forever.
UT: Apparently it was not forever as here we are. You are rather impatient if you think a few minutes is an eternity. Please hold and I will tell CP you are on the line.

CP: Thank you for holding. This is CP. How may I help you?
IRED: I need to phone in a prescription.
CP: Wunderbar! We love prescriptions.
IRED: I was on hold forever.
CP: And I was busy the whole time. I still am, but, here I am, talking to you. Now what is so important that you needed to call me, hang up, and call back again? It must be life-threatening. Is it Epi-Pens?
IRED: I need to call in Augmentin 875mg bid for 10 days.
CP: Seriously? Augmentin? AND you're calling from an office 45 minutes away? What makes this more important than the other 500 prescriptions I will fill today?
CP: You do know we have voicemail, right? It's the first option available after you select the "doctor's office" option. You called me twice so you should have heard it. Let me ask you a question...When I call your office and ask to speak to the nurse, what happens? I get put through to voicemail. I don't even get the chance to ask my question which is usually about an error on an e-script you sent over. The beauty of voicemail is the convenience of it. YOU get to leave your prescription at YOUR convenience and I get to retrieve it at MY convenience. I also get to rewind and replay it since you give prescriptions like the Micro Machines guy sells cars.
CP: The next time I call your office, I expect my call to be answered immediately by a nurse or the prescriber. I don't care if you're in a room. I don't care if you're drawing blood or giving shots or taking rectal temps with your thumb. If you can't be bothered to wait, or to use voicemail or your e-script software for that matter, while I am counseling a patient, administering shots, performing an MTM, taking prescriptions, retrieving voicemail, checking prescriptions, or any of the other tasks I need to do then you can extend me the same, common courtesy. I will just keep calling, hanging up, and calling back until you answer. Is that acceptable?

Friday, September 19, 2014

Dear Doctor

...I would like to invite you to visit my pharmacy. I would like to take you on a tour. I have been to your office before. I have seen how it is run. I know how long your wait times are. I know how long you spend with patients. I know how your staff treats their patients, and pharmacists who call them. I wish for you to know the same about me.

The main reason I would like you to visit is to show you how we receive prescriptions from your office, and all the other offices in the area.

It was very nice of you yesterday to see a hurried patient.
It was very nice of you to tell her you would encourage us to quickly fill her prescriptions.
The only problem is the method in which you chose to deliver your message: The Notes Section of an E-Script.
That is SO not the way to deliver an important message to the pharmacy.

(For the record, the message read: "Patient is leaving the office now and would like to pick this up in 30 minutes.")

I didn't see it.
When I check my work queue, I don't see messages. I see names. Patient names and drug names.
If you wish to convey a message with a sense of urgency, please choose a more appropriate, expeditious method. I would go so far as to suggest, and this is only a suggestion, that you personally walk to the phone and call in the prescription to me. I know, it seems ludicrous to think that prescribers can use phones and actually call pharmacies but hear me out on this.
Back in the way way back, this is how it used to work. Short of a patient bringing us a handwritten prescription, offices used the telephone to transmit orders. Guess what? That antiquated technology STILL WORKS! All you had to do was call me, add a sense of urgency to the order, and I would have put her among my waiters.

Instead, your order got lost among the other 35 e-scripts that dropped from 4-4:30pm on a busy Thursday and, get this, the patient got mad...AT ME!

From now on, when patients ask me to send refill requests to your office, I am going to have them stand at my counter and watch me. I am going to send their requests via telegraph. I will input every order in Morse Code and tell them their office will be writing them new prescriptions that will be ready at the front desk when they arrive and they should go now.

Refill Request. Stop. Your Patient. Stop. On Way Now. Stop.

Wednesday, September 17, 2014

Inventory Reduction

In pharmacy we must always be mindful of our inventory. We must improve our turns, keep inventory low, and order profit-friendly NDCs.
Manufacturers have these same issues.
When you market a "new" medication, you want it to be a game changer. You expect to sell it by the bushel. What if that doesn't happen?
You get this quick, witty conversation at work.

CP's Partner: Why did you run this through for the 30 count NDC?
CP: Because the Rx was written for 30 tablets and I don't think we'll use it again.
CPP: Great minds think alike.
CP: Indeed.
CPP: Only one problem.
CP: What's that?
CPP: They quit making the 30-count NDC.
CP: Of course.
CPP: We can only order the 90-count NDC now.
CP: Right. Well when you have a groundbreaking drug such as this you want to sell as much as you can.
CPP: Did you just call Gralise a "groundbreaking drug".
CP: I did.
CPP: Your cynicism just made me spit out my coffee.
CP: Thanks. Think about it. They took plain old Gabapentin, made an extended-release form of it and charged triple. No one prescribes it because it's rarely covered and the generic is much cheaper. Now how does a company with a failed brand get rid of their inventory? They package all their slow-moving product in larger bottles forcing pharmacies to order sizes they don't need. This puts the burden on the pharmacies to get rid of the inventory. Manufacturer's warehouses are emptier, product has been sold and paid for, profits improve. Pharmacies are stuck with partial bottles waiting to expire. Think of all those Duexis prescriptions we received.
CPP: Another fine groundbreaking drug.
CP: Indeed...Right you are, Ken...

Monday, September 15, 2014

Just Stop...

Change can be good. It can be difficult to accept at first. People are often resistant to new ways of thinking. Sometimes this is because they are accustomed to and comfortable with the old way. Sometimes they fight because they cannot see how the new way will be better than the old. The definition of insanity is doing the same thing over and over and over expecting a different result. What if we gave people no choice but to accept the "new normal"? Would civilization as we know it end? Would the markets crash? Would the world stop revolving? No. Life would go on as it always has after these Earth-shattering events. Now, how does this relate to pharmacy?

I was told by a corporate pharmacy suit that "as long as everyone else is doing it, we need to as well". He went on to say that "as long as we have a chip in the game we can sit at the table". Brilliant. This is the thinking that has advanced our profession backwards over the last couple decades.

Ideas: Stop all coupons. Stop all transfer incentives. Stop all gift cards. Stop all Perks programs. Stop using my profession to generate FE business. Better yet; get out of the FE business altogether. If you give a group of children 7 choices of flavors on anything, they cannot make a decision. Give them one option, or perhaps two, and they will make it quicker. Same with pharmacy. Remember when they took away all analog TV? People fought it, cried about it, government legislated on it and there were constant battles about it. Guess what happened? The day came, the switch was thrown, and nothing happened. It's a tough decision to get rid of one's security blankie, their lifesaver, teddy bear, or crutch. At some point, they have to learn to grow up and walk/survive without them. It's time for pharmacy corporations to man up and just not do it anymore. People complained, people got upset, people were revolting (some still are-wink wink). But they survived. I like it. I went shopping today and everyone was trying to figure out how to use coupons at the 3 places I visited. Some coupons weren't valid on certain products, at certain hours, on certain sizes, in combination with other offers, whatever. The point is, I spent more time waiting for people to use their coupons and figure out sales ads today than I did actually shopping for what I needed. Make it stop. The Profession of Pharmacy needs to go back to when it was respected as just that, a Profession.

If they want to focus on healthcare and the profession, I am all for ways to do it. I have no problems with immunizations, MTMs, clinics, etc in my pharmacies. Just focus the money from advertising and gift cards on adding support to facilitate these programs. I could do all of these more efficiently if you gave me extra help. We have no adaptability or flexibility. Our corporations are strictly dollars-and-cents types. First cuts are to labor. In the next breath it's improve your customer service. It's like telling a kid to keep clapping after cutting off one of his arms; cruel, yet somehow expected to work or he'll be put in timeout.

Seriously consider charging for everything. Doctors expect us to fax them refill requests? Charge for them. Patients expect us to call or fax for refill requests? Charge them. Prior Authorizations need faxed? That's a charge too. You need a few pills or you'll die over the weekend? There's a fee for that. I have a great post dedicated to nickel-and-diming doctors and patients over error-filled prescriptions. Time to revolutionize the industry. Get everyone on board. Change the game. The players will adapt. If everyone signs on, there will be no "well Wal-Mart doesn't do that so I'll go there". Make it the new pharmacy professional standard.

Friday, September 12, 2014

If Patients Treated Their Prescribers' Offices as They Treat Us...

... and I am certain they do. It is something we share. A common bond. Like a school shares germs and a lice outbreak. I would be interested in hearing how the conversations I have at the pharmacy sound at the office...

1.Just call in whatever you called in for me last time.
2. Just call it in wherever you sent it last time.
(I'll just go wherever I think that is anyway and yell at them.)
3. I don't know what it is. It's right there in my chart. Can't you just look it up?
4. What do you mean the pharmacy didn't fax you?! I was right there when she clicked "fax". She said she sent it. I watched her.
5. What do you mean I have to call my own pharmacy and have them request a refill? I'm standing right here!
6. I need everything refilled I've had prescribed over the last year. Yes. Of course I mean the yeast infection cream from last January! I said everything, didn't I? No. Not the inhaler stupid.
7. It's my pre-med! I need it now! My dentist appointment is right now and I was supposed to take this a half hour ago but you people didn't open until now so it's all your fault if I have to reschedule!
8. I've been on this for years. What do you mean "no refills until I come in for an appointment!"? He said I'd be on this until I die.
(Apparently he is trying to hasten my demise.)
9. What do you mean I have a $20 copay? Did you bill my insurance? Why the hell do I pay so much to have premium insurance if you're going to charge me $20 every time.
10. Well the other doctor I go to across town doesn't charge me anything.
11. My pharmacy said my office visit would be $4.
12. They said this exam was on your "Free" list.
13. What do you mean I have to wait for my appointment? There's no one here in this waiting room.
14. All you have to do is put me in a room and squeeze that little bulb thingy.
15. Wow. You guys must be slow today. There's no one here.
16. How long is this going to take? I just picked up ice cream from the grocery store and it's melting in my car.
17. I need the little white one, the oblong white one, the roundish off-white one, and some green or blue tablet or capsule or something plus my cream or ointment...or maybe the gel. <click>
18. No I do not have my insurance card with me. I've been coming here since before you were born.
19. No, I've never been seen but my husband has. It's all the same information.
20. Why do you need my date of birth? I'm not telling you that. That's private. You're going to steal my identity.

Receptionist: How may I help you?
Every Patient: I need to speak to the doctor.
Receptionist: Is there something I can help you with?
EP: No. I just need to speak to the doctor.
Dr. Zoffis: How may I help you?
EP: I need to schedule an appointment...

Receptionist: Ma'am, why are you ripping pages out of all our magazines?
Proactive Patient: I'm taking out all the drug ads so I know what to tell the doctor I need today.

Receptionist: <picks up phone> Hello?
PP: What's taking so long?
Receptionist: Are you calling me from the waiting room?
PP: Yes.

Thursday, September 11, 2014

If the Real World Worked the Way People Believe Pharmacy Does...IV

Crazy. But that's how it goes...I know that things are going wrong for me. You've gotta listen to my words...

Sprint Service: Thank you for calling the SS today, how may I help you?
CP: Yeah. I got this letter in the mail?
SS: That's a statement with a Canadian inflection at the end making it sound like a question. Do you have a question? Question mark?
CP: I got this letter and I want to know why you people sent it to me! Exclamation point!
SS: We send all types of letters to your house. Some are bills. Some are offers for new services. Some are advertisements for new phones.
CP: YOU people sent them to me. Why don't YOU know what it is?
SS: Our corporate sends those to households. They do not come from this local retail outlet. If you are a current customer you could receive every one of the mailings that go out across the country, including a bill or reminder that your contract is expired and needs renewed.
CP: Can't you just look it up?
SS: No. That's pretty much the point of sending the letter. To communicate a message to you in a readily retrievable form so we don't have to know why we contacted you.
CP: Well I didn't get the mail this morning so how am I supposed to know what it is? Someone told me there was mail from the SS on my counter and I want to know why!
SS: Do you have the mailing in front of you?
CP: Yes.
SS: Do you have a knife or letter opener with you?
CP: Yes.
SS: Carefully slide the knife along your jugular vein then stab yourself in the eye.
CP: How will that help?
SS: It will rather abruptly end this silly phone call.
CP: Sounds painful.
SS: Much like this phone call.
CP: Other options?
SS: Open. The. Letter...then Read. The. Letter.
CP: It says my contract needs renewed. Can you do that for me?
SS: No. You'll have to call the sales department for that.
CP: But Verizon called for me.
SS: I'm sure they did. This is not Verizon. This is Sprint. If you like their service and products better, perhaps you would be interested in contacting them.
CP: I don't understand. My pharmacy always calls my prescriber for me. They refill my prescriptions for me, they call me when they are ready to pick up, they do everything for me.
SS: This is the real world, not the pharmacy. We actually expect you to take care of your own life. You want a phone? You call the phone company. You want a cheeseburger? You drive to McDonald's. No one is going to randomly call you soliciting business and offering to do everything for you. There is no business called Let Me Be Your Bitch. No one does that.
CP: My pharmacy does.
SS: Your pharmacy is a whore.

Maybe I'm the one who is the schizophrenic psycho...

Wednesday, September 10, 2014

If the Real World Worked As People Believe Pharmacy Does...III

Bottle of white. Bottle of red. Perhaps a bottle of rose instead...I'll meet you any time you want, in our Italian restaurant...
Restaurant Host: How may I help you this evening?
CP: I am here to pick up a pizza that should have been ordered earlier.
RH: For what name?
CP: Pharmacist...Cynical Pharmacist.
RH: Charming. I am sorry, but I do not see an order for that name. What is your phone number?
CP: We have 7 phone numbers at the house. It could be any of these.
RH: Nope. I am sorry but we have not received an order yet.
CP: Can you check the voicemail?
RH: We don't have voicemail. We answer all our calls. 
CP: How about the fax or the computer? 
RH: Who uses a fax anymore? And our online order system is empty. 
CP: Can you check again?
RH: It is not here. There are the completed carryouts and to-go orders being made.
CP: How long is it going to take?
RH: For what?
CP: To make my order?
RH: I have to receive it first and as I've OVERstated, that has not happened.
CP: Can you tell me when they will call it in?
RH: Who?
CP: My family! They were supposed to call earlier. I just left home and they said it would be ready when I got here!
RH: You want ME to tell YOU when I think YOUR family will call in YOUR order?
CP: Yes! This logic works at my pharmacy for some reason.

Tuesday, September 9, 2014

Hardest Concept...

Most difficult explanation...Why you cannot get two Albuterol Inhalers at a time.

Why is this so difficult to understand?
A single Proair HFA inhaler contains 200 puffs. If your doctor instructed you to use 2 puffs every 4 hours then you could use up to 12 puffs in a day. At the maximum 12 puffs per day, this means your inhaler would last 16.67 days. Two inhalers would last 33.33 days. With me so far?

Now, your insurance will only pay for a maximum of a 30 day supply. Last I checked, 33.33 is greater than 30. Since we cannot simply prime 40 puffs out of 1 inhaler, we have to dispense a single inhaler. Yes, I do agree that your child may need an extra one for school.
Yes, he may need one for his soccer bag.
You are welcome to pay cash for the second inhaler.
You could have come in over the summer when he didn't needed it as frequently and refilled an extra one that would be designated as "The School Inhaler".
If he really uses it every 4 hours around the clock...then he only gets 4 hours of sleep which isn't good either.
You could plan ahead.
You could call your insurance for an override.
If your child really is that dependent upon his little albuterol inhaler then you know how to deal with this.
If he is actually using one inhaler every 16-17 days then perhaps he needs to be on another medication.
If he is NOT using one that frequently, then please don't fret. He can get the refill in about 12 days. I think he'll make it until then.


One of the more difficult conversations to have with a patient is about the "salt form" of their medications. It is tricky when one pharmacy puts the salt suffix on the label while another does not. Another problem occurs when one manufacturer's name gets truncated by the computer. It makes for some rather interesting inquiries.

"What do you mean it has a salt in it? I'm on a salt-free diet."
"What is H-C-I anyway?" (That's a lower case "L". It's Hydrochloride.)
"Last time my label said 'Metoprolol Tart. Now it says Succ.' Why does it say suck? I want the 'tarts' not the 'succs'."
"It says Ferrous Sulf. I'm allergic to Sulfa. Is that the same?"
"Can I take Calcium Citrate if I'm not allowed to eat grapefruit? It's a citrus."
"Salts? Like Bath Salts? I don't want that."

Monday, September 8, 2014

Why Insurances Suck

A short time ago a medication was on backorder. A real surprise, I know. At the time the only version available was a single manufacturer supplying blister packs. While they are a pain to deal with, at least we could provide the medication to our patients...until the pesky insurances got involved.
We received many "NDC not covered" rejects.
We called for overrides.
Some insurances were obliging, others were not.

This is one of those conversations:
Insurance Guy: How may I help you?
CP: I need to request an override for an NDC not covered rejection.
IG: For what reason?
CP: It is a blister-pack NDC and, unfortunately, the only one available.
IG: It's not covered.
CP: I know this, hence the rejection. Since we care about our patients, unlike their insurance companies, we were able to find the product for them and now are trying to dispense it to them.
IG: My computer shows this is not the only NDC available.
CP: But it is. We have been ordering this for 2 weeks and this is the only one we cold procure.
IG: The insurance won't pay for it since these others are available.
CP: Fine. Give me the NDCs your "magic computer" says are available.
<gives me 3 NDCs>
CP: Great. Those are 3 of the ones we have been ordering from all of our suppliers and, guess what? Not available.
IG: My computer shows they are.
CP: Well since your magic computer shows they are out there, can it also tell me where I can find them? Can it order them for me? Does it have real-time data that shows the inventory of every warehouse in the country?
IG: "No. It's not a magic computer." (Yes. I actually got him to say this.)
CP: Since I call and look online at the warehouses every day, and have been trying to order this for 2 weeks with no success, I think I would know better than your broken "magic computer" what is and is not available in the marketplace.
IG: "I don't have a magic computer." (He did it again.)
CP: Can you just please allow an override for this patient so I can get on with my day?
IG: No. My computer says it's available.
CP: Ugh. Okay. I'll call back and get someone who'll just put in the override with his magic computer.
IG: It's not...
CP: <click>

Called back. Got someone else. They put in the override. He agreed he doesn't have a magic computer either, but he also knew there were supply issues. It may have been exhausting, but it was fun.

Sunday, September 7, 2014

Throw Me a Bone Here

Did you ever feel as if you walked into a conversation midway and you were expected to know what the person was thinking in their head as they started the discussion there? It happens in pharmacy all the time. 

Helpful Spouse: My husband needs his eye drops. 
CP: Okay. 
HS: Can you recommend something? 
CP: Um. What am I missing? 
HS: He is out of his eye drops! What can I get him over the counter that is similar?
CP: Similar to what? What is he using?
HS: I don't know the name of them. 
CP: <knowing how this could go, but asking anyway> What are they for? 
HS: His eyes! 
CP: <yep. saw that one coming> For what purpose? 
HS: To keep him from going blind!
CP: Uh-huh. It sounds like a prescription medication. Let me check his profile. 
HS: I don't know where he got them from. 
CP: Well he hasn't filled any eye drop with us...ever. 
HS: So you can't recommend anything? 
CP: Do you have the old bottle at home? 
HS: No. 
CP: Of course not. You are pressuring me for a recommendation over the counter to help your husband. Is that correct?
HS: Yes. 
CP: You do not know where he got them. You do not know the name of the them. You do not know the correct indication for them. You do not know how long he has used them. The only thing you know is that it's some type of eye drop. Is that correct? 
HS: Yes. What can I do?
CP: Short of having him call his doctor on Monday? 
HS: Yes. 
CP: Buy him a little white cane with a red tip. 

Friday, September 5, 2014

Professional Services

Since we may, at some point, eventually, possibly, conceivably be considered to be actual health care providers, I think we should be able to bill as such.
The groundwork is already set.
In order to provide immunizations, we have to have an NPI number. This is how insurances pay the person who provided the care. Let's start here.
I fully believe in pharmacists providing immunizations as part of their professional practice. However, I also believe in at-will participation. Companies have forced everyone to be certified. Not really an issue now since every graduate for the last decade is certified. I used to teach the certification classes. I had pharmacists refer their patients to my store because they didn't want to mess with them. Fine. The company only cared that they were certified; not if they actually administered any vaccinations.
Let's make it a law that pharmacists can bill for these services using their NPI numbers. Here's how it works.
A flu shot costs the pharmacy about $9 a dose. (Throw in the average Rx cost withOUT medication of $10.00 and the total cost to dispense and administer is $19.00 per shot.) They charge around $25-$35 per shot. Why? Because that's what Medicare will pay them for it. Who gets the profits? Not the pharmacist who administers the shot.
What if a store has 4 pharmacists and only 2 choose to give shots and always defer to the others? What if floaters never want to administer them while floating? Simple, those who administer get more money. Those who don't, don't. Just because a company made everyone go through training, doesn't mean everyone does the work in practice. It means those who do not want to give shots have no obligation to do so.
If you don't want to give shots, you are happy because someone else will.
If you want to give them, you will get paid for them.
The company is happy because they are still making money off of them.
Those who wish to do more (off-site clinics, working with the local Departments of Health, etc) can have more recognition and compensation for their efforts.

It's the same with MTMs. Companies like to tell us how much money WE can earn THEM with MTMs. "Your store can realise $2452.79 if you were to complete all of these." Yes. The STORE can realise that, but I cannot. I need to be able to put in my NPI when billing flu shots and MTMs and receive the money for them.
If you want your employees to make more money for YOU, you need to share with them since they are, you know, doing the actual work.

Wednesday, September 3, 2014

It's the Prescribers' (terrorists') Fault

Let us suppose a terrorist group poisons a town's water supply.
Let us suppose that they are seen dumping millions of gallons of chemicals into the reservoir.
Let us suppose that thousands of people will die from this act.
Let us suppose that these three things happen every year.

Let us suppose that the water treatment facility does its best to clean the water.
Let us suppose the media are alerted and the residents should know not to drink the water.

People are outraged that their family members are dying.
People want answers.
People want justice.
People want someone to blame.

In this scenario, where does the blame lie for the deaths?
Is it with the terrorists who are polluting the water?
Is it with the government thats knows about the poisoning but has yet to act?
Is it with the people for drinking the water?
Or is it with the water treatment facility that is trying its hardest to clean the water?

Let us suppose the terrorists are prescribers who write for controlled medications.
Let us suppose they are known to prescribe large amounts of these medications with reckless abandon  in the local community.
Let us suppose that thousands of people will die from this act.
Let us suppose that these three things happen every year.

Let us suppose the water treatment facility is the pharmacy.
Let us suppose the media are the DEA and State Boards of Pharmacy and Medicine and they have been alerted that these prescribers are rogue and there is an epidemic of drug abuse and people should avoid these prescribers.

With these word changes, who is to blame now?
Blame should still be placed squarely on the first step of the process-the act of terrorism.

The current way of thinking is to blame the pharmacies for the abuse of medications in this country.
We have already seen in that Tramadol has become a controlled substance and that all Hydrocodone containing products were rescheduled as CII medications. This is all to regulate the end of the line. It's like blaming fishermen for returning with smaller catches when companies upriver are openly polluting the water. To further emphasize this with the water treatment analogy: this would be like the government putting more testing and paperwork requirements on the facility while telling the terrorists "it's okay, we got this".

I realize the AMA has a powerful lobby and the pharmacists do not. (Nice try APhA, but you're the little kid on the playground who gets pushed down and his lunch money stolen by the bigger kids.) This should not mean we should be the gatekeepers in the DEA's failed war on drugs. (It has failed due to the backwards thinking outlined above.)

Prescribers and pharmacists have the same access to the same tools.
Prescribers have the right to NOT write prescriptions.
Pharmacists have to right to NOT fill prescriptions.
Why do pharmacists get in trouble for filling prescriptions that should never have been written?
Purdue has a list of rogue Oxycontin writers but they refuse to share it with authorities.
Pharmacies have a list of rogue prescribers but no one wants to take it or investigate it. (Or no one has the time or authority and the AMA would not assist.)
Until this country figures out where the blame lies, controlled medications will continue to find their way into the wrong hands and onto the streets and there will be two innocent groups who have to pay the price: Pharmacists and Legitimate Patients.