Do You Wanna Get a Flu Shot?

Why do people still schedule appointments with their prescriber's office for flu shots?
(Unless your insurance mandates this, which few do anymore, this is a good question.)

Funny observation from my recent office visit:
The guy in front of me arrived at 1:02 for a scheduled 1:15 flu shot. He brought his 18yo daughter for her shot appointment at 1:25.
The guy behind me arrived at 1:03 for a 1:15 flu shot as well.
They checked in and were give a clipboard with the routine questionnaire attached for them to complete while they waited.

The process looked a little surreal to me.
Here, in a prescriber's office, people walked up to a counter and quietly, patiently waited in line to check in. They quietly and patiently sat while completing their paperwork. They waited quietly until they were beckoned to the back by Lady Stabber. They proceeded to checkout and quietly paid their copay. They left without making a sound, a fuss, a commotion. They did not cause a ruckus, create a scene, remonstrate with the staff, or exhibit any of the character traits associated with the Pharmacy Phlu Shot encounter.

Father and daughter were there over half an hour.
I would have processed, billed, administered, and checked out both of them on any day in 20 minutes. They could have come before work, after work, at lunch, on the weekend, and the result would have been the same. Why do people continue to make appointments at their offices solely for a flu shot? To me, that is not convenient. One of my patients, when I asked her about getting her flu shot, told me she didn't know we gave them (see marketing people! you are failing here) and instead went to a competitor she happened to be driving by simply because they had a sign out front.

Note: You can call ahead and let us process your prescription on your insurance before you arrive. This way, as with the office above, all that is now required of you is to complete the paperwork.

My two questions I will leave you with today:
1. Why do people continue to make flu shot appointments with their prescribers (solely for that purpose)?
2. Why do people act so much differently in these offices when their wait is longer?
3. (Bonus Question) Why are they so HAPPY to wait longer in the office for a flu shot?

It was the Fever

Some excuses are not acceptable for certain situations.

I took a voicemail for Bentyl 10mg capsules. Listened to it twice, as always. Definitely Bentyl.

Next day, as I am talking to my partner, I am informed that the patient complained he received the wrong medication. Here is how my partner explained it to me:

CP's Partner: Make sure you write this down for your little page.
CP: Curiosity is piqued. Do tell.
CPP: Had this conversation with a nurse this morning after the patient called to inquire as to why his medication looked really really different.
CP: Okay.
CPP: I talked with him then called the office. Turns out I was able to get transferred to the actual Voicemail Nurse who phoned in the actual prescription!
CP: No way!
CPP: Way! I asked her if she remembered calling in the prescription.

----
CPP: Do you remember calling in the prescription?
VN: Yeah. That was me.
CPP: The patient said it was supposed to be for Reglan 10mg tablets.
VN: "Yeah. I had a fever that day so I'm not really sure what I said." (actual quote)
----

CP: She actually said that?
CPP: Yep.
CP: As if that's in any way an acceptable excuse?
CPP: Yep.
CP: I think the only time "I have a fever" is acceptable is when it comes from Christopher Walken and he wants more cowbell.
CPP: Maybe we can use that from now on in our pharmacy.
CP: Why is the wait 15 minutes?
CPP: I have a fever.
CP: Why did you miss your sales and script count goals?
CPP: Fevers.
CP: Tech Budget?
CPP: Fever.
CP: Why did you short me 27 Oxycodone?
CPP: We didn't. We count by fives. We never miss by an odd number. Are you febrile?

CP: So basically she blamed a fever for her error? An error which could have, though not likely in this case, been detrimental to a patient's health had he not been so vigilant?
CPP: Correct.
CP: I don't suppose they are one of our frequent e-script offenders too?
CPP: It wouldn't surprise me.
CP: Did you document her words?
CPP: Verbatim.
CP: This whole thing gave me a fever. Make sure we add that office to our "do-not-ever-let-this-doctor-take-care-of-me-or-my-family" list.
CPP: Definitely...once my fever goes away.

Find the Error

Okay, class. Pay attention. Welcome to the first day of school. My name is CP and I will be your instructor through these lessons. We are gathered here today to learn about this thing called Electronic Prescribing.

(oohs and ahhs from the crowd.)

When I was in school, our prophessors would show us examples of error-filled prescriptions. We had to identify what was missing, added, incorrect, or illegal and correct it. Here is my plan going forward. 

We are going to collect all of the error-filled prescriptions throughout the day. At the end of the day, we will remove all patient-identifying information from these prescriptions. We will then attach a fax cover sheet to each of these that reads: 

"Our Pharmacy received this error-plagued electronic prescription from you or one of your colleagues today. Please take the time to examine the mistakes that were made. We circled the number of errors so you would know how many to find. Bonus points if you can find all of them. In order for us to not send your error-filled prescriptions to the State Boards, please correctly remedy your colleagues' prescriptions. For every one that you fix correctly, we will remove one of yours from the Boards' pile.  Also, please feel free to contact your colleague and make phun of him or her for their gross ineptitude. 

We will then fax this, along with the prescriptions to all the local prescriber offices. The prescribers who send back the fewest corrected prescriptions each month will be placed onto the naughty list along with the prescribers who made the most errors during the month. It will be quite interesting to see how many corrected ones we get back. At the end of each month, we will forward both of these lists to the State Medical and Pharmacy Boards.  

After a while, you will learn you do NOT want to be on our list. 

Perhaps we could give kudos to those offices that mend their ways. We could ask them to post one of those "XX Days without being made fun of by CP" boards in their offices. 

Check out the Monty Python Blackmail sketch here...

Monty Python Blackmail

or for the shorter, more relevant version, click here...

http://youtu.be/xrRZVCg31fE?t=1m24s

Plan Ahead

It helps to plan ahead.
It helps to prepare.
While sometimes it is okay to just wing it, this is not always the case.
Be prepared.
Save yourself some time.
Save me some time.
More importantly, save everyone else some time.

Sunday, 11am, a man approaches the counter.

Strange Little Man: I need to have this filled.
CP: Hooray! One more and I get a cookie! Do you wish to wait?
SLM: No. I am going to go home and try to find a discount card for this.
CP: Okay. Sounds like time well spent.
SLM: It is. I get this every month and always find a card to save me money off my copay.
CP: Great. May I pester you for a moment over this whole scenario?
SLM: Sure.
CP: I notice here that this prescription was written 10 days ago.
SLM: That is correct.
CP: You say you get this every month.
SLM: Yes.
CP: You say you bring me a new discount card every month.
SLM: Correct.
CP: May I ask why it is then that you would hold onto this for 10 days, grab it off your kitchen table, drive it down here, leave it for me to fill, THEN drive back home to do some research online to find a coupon which you will bring back to me later which I will have to spend twice as long trying rebill as I needed to initially fill it, all the while backing up my pick up process and making everyone behind wait even longer for their prescriptions than is necessary?
SLM: I wanted you to get started on it.
CP: And at no point in the last 10 days, or this morning, did you think to research this coupon you bring me every month? Shouldn't you have it bookmarked or favorited somewhere?

Fast forward to 4:15 pm, after the football game and just as pickup time is peaking because we close at 5pm and SLM enters...

SLM: Here is the coupon I found.
CP: It took 5 hours to research this?
SLM: And watch the game.
CP: Okay. You do realise that I have to put all this information in the computer, reprocess it, and call them because what you gave me isn't working, right?
SLM: No. I know this happens every time though.
CP: Then perhaps you should print this BEFORE you bring me the prescription so I have plenty of time to fix it. There are now 11 people behind you in line, all of whom also watched the game and now wish to pick up their prescriptions before I close. You should apologise to them, and buy each of them a soda with the huge savings you are expecting with this coupon card.
SLM: Golly, that sounds swell!
CP: I know. Makes me pine for the days when we had soda fountains...

Walking With a Limp

I was once told by some HR prick that my mouth would get me in trouble. He may have been right as I seem to have #NoFilter when it comes to my customer interactions. Mind you, these are not your typical, run-of-the-mill interactions. These are the ones where I defend my honour and that of my technicians...and try to one-up the belligerent arse standing across from me. One of my most important rules in my pharmacies has always been defending my technicians. They don't get paid enough to put up with the bullish!t spewing across the counter and no one is allowed to treat them worse than I do.

Which brings me to today's witty tete-a-tete.
Uber-Tech: Mr. Limp Bizkit over there would like to use this coupon for his 3 free tablets.
CP: Okay. Tell him to hold on a bit longer and I shall try to work my magic.

(mere minutes pass...)
CP: Please tell MLB that he already used the 3 free coupon and has to use the other one for a discounted copay.
MLB: What? I wanted all of them! Why is this taking so damn long? That's not what I told her!
CP: Wow. I counted 3 exclamation points there. You need help.
MLB: I asked her for all of them.
CP: And just how many would that be, exactly?
MLB: I. SAID. ALL!
CP: Well let's see. Your prescription was written for 10. Your insurance pays for 6 per fill. Your coupon discounts only 3 at a time. So which "ALL" do you want? The ALL 10 originally prescribed? Or...
MLB: How hard is it?
CP: Apparently not very...
MLB: Jesus Christ!
CP: He won't help you...and he also doesn't need this. He was able to rise from the dead with no help. Beat that!
MLB: There is no reason I should have to wait over 2 hours here for this.
CP: You are correct. There is no reason. So why are you?
MLB: What?
CP: Why are you waiting? Just take your stuff and go. We filled it exactly 2 hours ago...right when your doctor sent it to us. It was ready to go...2 hours ago. All you had to do was pay for it instead of giving my tech a hard, sorry, difficult, time. YOU asked ME to change the billing. YOU asked ME to change the quantity. YOU are keeping YOU here waiting for all of this when all you have to do is PAY and LEAVE.
MLB: This is ridiculous. You people don't know what you're doing.
CP: By the way, the cost for ALL 10 of them will be $300.
MLB: Just give me my damn blood pressure medication.
CP: Yes. You definitely need that.
MLB: (mumbles under breath as he storms off...)
CP: Have a good night, sir!

(MLB returned a short while later and started in on another of my techs...)
MLB: Why didn't you give me my 3 free tablets?
CP: Because it is a once-per-lifetime offer.
MLB: And I used this 2 years ago!
CP: Did you die and come back to life sometime in the last 2 years?
MLB: No. That's ridiculous and you're an ass.
CP: Thank you. And if you hadn't worried about interrupting me every time I went to explain the rules, you would have had your answers, not had to come back, and probably be an hour closer to "action time".
MLB: Your problem is you think you know everything.
CP: And your problem is that you don't realise I do know everything. Now go away or I shall taunt you a third time.
MLB: Ass.
CP: Have a good night!

Discount Card Cheerleaders

Discount Cards are swell. They promise big but always come up short. The only thing missing from the magazine and mail promotions is Billy Mays. These discount cards practically scream at you that they will save you tons of money off your prescriptions. While it is true that the insurance-less folk out there will save a few dollars off retail prices, the promised savings ranges are rarely, if ever, truly realised. As with all advertisements, people fall for the bold print and BIG type and focus on the "up to 90% OFF" and ignore the little asterisk explaining the only way to receive UP TO 90% off would be to only purchase 10% of a prescription.

Patients expect something that is mailed to them, for free, to provide them with unlimited savings. Where else does this really happen? Are these the people that click every link in their spam folder expecting enhancements?
When patients come up to the counter with these decks of cards I think they expect Monty Hall and a group of cheerleaders with pompoms to suddenly appear in a shower of confetti and start cheering: "Take it off! Take it off! How low can you go?"

*Please note: This is specific to general discount cards and NOT manufacturer-/medication-specific copay cards. That's another rant...

One Prescription Equals One Prescription

How long does it take to fill one prescription? From start to finish?
How long does it take to process it?
To type it and bill the insurance?
How long does it take to count it?
To label it?
How long to check it?

Assuming nothing is wrong with it that needs fixed, how long does it take for one lousy prescription?

I know there are companies out there that, if a technician is not allowed to count the prescription (CIIs), then these are not included in the totals used for tech budgets. I call shenanigans.

The big problem I have is not including prescriptions put on file.
They still need scanned.
They still need typed.
They still need checked.
They often still get billed to insurances (often e-scripts sent that may be a few days too soon or that the patient had filled at mail order or any of the myriad reasons for us to try to process the claim). These often take longer because we have to process them, get a rejection, research it, call on it, or send a prior auth for it. Either way, at least as much work goes into one of these as a regular, filled Rx for which we receive credit.
They still need checked by the pharmacist.
The only real difference is the missing step of "just putting pills in a bottle".

One day recently, we filled over 400 prescriptions. On the same day, because I counted them, we processed over 40 prescriptions that were put on hold. This means my numbers would have been improved by 10% for my staffing if these prescriptions, which require just as much effort to process, had been included in my totals.

While I realise we do not get any payment from anyone for prescriptions not actually filled and picked up, it does not change the amount of work that we the people need to perform.

We want people to get shingles shots.
They want to know how much it is.
We process their prescription. We bill their insurance. We get a label. We tell them it is $50.00. They balk at the price because next year they are switching Medicare D plans and it will be free. They don't want it. Now you back out the claim and put it on file. How long did it take? How much did you make? Do you get credit for the time it took away from processing something else?
No. You get nothing.
It IS your job to process these. We have a lot of prescribers in our area who send e-scripts for an entire patient's profile with the note: "Please hold. Do not fill until patient requests." This is great. It means we do not waste our time filling them only to have to return them in 13 days. However, I still have to do most of the same work just to file them.

When corporate bosses ask why your numbers are down, you cannot point to all the scripts you filed and almost filled. (I understand we will get credit when we actually fill them in the phuture.)
If you are going to base my pharmacist and technician hours on the amount of prescriptions we DO it should include the ones we PROCESS and NOT just the ones we fill.
Just because WE don't COUNT doesn't me THEY shouldn't count.

Hercules! Hercules!

I had a new experience yesterday while administering flu shots. They say expect the unexpected. I saw a fine couple in their early sixties at the counter paying for their shots. I overheard someone mention "we have a cryer over here". I saw the gentleman in the T-Shirt pictured and figured it couldn't be him.

As I enter the room, Mr. Big Guns was slunk down in his chair, hand over his eyes. After finishing his wife's shot, I moved in for the kill shot. One thing I have practiced with my technique is to talk while I approach with my needle. The second thing I have developed is the "pump fake". This really came in handy as he flinched so much I thought he might have turned to stone. Once he thought it was over and relaxed, I went in for the kill. The entire time he spent blubbering and sniveling.

Phew, flu shot over...
...aaaaand he's getting Pneumovax too. Here we go again...

Policies and Procedures

I wish corporate would just stop making new policies and procedures. Our pharmacy is beginning to look like this:

Corporate Hypocrisy

Dear CP,
Here's a little story I've got to tell...
I thought you might find this relevant to your site.
Over the last several months, we have been instructed by The Powers That Be (TPTB) to reduce our inventory. Always a good idea, right? It would be better if they'd quit changing manufacturers on us, but that's another rant you can explore later.

Here is what happened. (Just as I predicted and yet somehow, TPTB didn't see it coming.)
We were told to reduce inventory. We spent months working on this. Eventually the congratulatory emails arrived from TPTB patting us all on the back for the work we've done and how much money we saved them and yadda yadda yadda more TPTB blather. We were heroes in their eyes.
And then...
We noticed that we were owing more and more people more and more items every day. We used to only have to owe, on average, 3 people per day. Now that total is just under 20 per day. That is only within the last 4 weeks.
And then...
TPTB sent emails out to us in the trenches that went like this: We have seen a large spike in customer service calls that point to not having products in stock as the number one issue.
Seriously. TPTB cannot be surprised by this. We knew it would happen. It would not have been so bad if they hadn't continued with the whole "surprised act" when they said: Make sure you call CUSTOMERS to tell them you are out of stock.

Yes! Because that is the reason they are pissed at us. It's not because we didn't have it in the first place, it's because we neglected to tell them that. See, if I were a PATIENT of a certain purveyor of health, and this particular place never had my health in stock, I'd be pissed at them for that. I don't care if they always called me. I'd see their name on my phone and think to myself "gee, they must not have my medication in stock...again".

I realize there is a balance. I realize we cannot control manufacturer backorders. I know as well as you do that we cannot stock lots of everything for everybody. That is reasonable. What is not reasonable is owing people basic medications. I ask you, O Wise One, have others experienced the same type of hypocrisy when it comes to inventory and stupid customer service metrics?

Dear Anonymous,
You must bring balance to the Force. No decisions ever made by corporate make sense. It's a little like God making the platypus. Sometimes you just have to say WTF? and move on. We truly are a damned if you do, damned if you don't profession.
Inventory too high? Your fault.
Inventory too low? Your fault.
People unhappy about stocking issues? Your fault.
Increased complaints about inventory from patients? Your fault.

I do find your story hilarious that they expect complaints to disappear simply because you call the patients. We call them too but it's a huge inconvenience for people to wait a full day for something they may need to start right away. Another issue I see with your comment is that your boss didn't take into account people who are waiting. You could tell them right to their face they have to come back for it. It's not going to make them any less pissed, but it will likely still generate a complaint. You did your due diligence and were proactive but it doesn't change the fact that you are out of the medication and the patient has to return. If they can figure out that we are going to give 1138 flu shots this year, they should be able to project how much Omeprazole and Ondansetron we are going to use.

Working with the Public

When did it become acceptable for those working with the public to just have to take it? Was it corporations deciding to focus on "customer service metrics"? Why is it that with nearly every post I write lamenting the state of retail, people comment that that's how retail is supposed to be?
I say that's bullshit. Why do we allow EVERY retail worker to be treated like crap? Is it just because "it's the public"? Since when is that an excuse to act like an intolerable git? I never walk into a retail outlet and say "today I'm going to throw a tantrum and hold my breath and swear at and belittle the clerks until I get my way". Never! But we as Americans willingly accept this as "acceptable public behaviour". Why?
I hate when people throw "whatever happened to 'the customer is always right?'" in my face as if that's some sort of argument ender. There are two flaws with that statement. First, you are not a customer, you are a patient. Second, you are not leaving with a product, you are leaving with your health. Hardly quantifiable.
People talk about how bad things would be if, one morning, some group decided to stop working. Could you imagine a day with no retail outlet open? We are no longer a manufacturing country. We are a retail country. We sell stuff. Lots of it. Let's empower everyone to fight back. Let's all walk out one day.

With National Pharmacist Month upon us in October, people have been asking me to start a campaign to get pharmacists organized in a Walk Out Day. Great idea...expect we pharmacists are all talk and no action.
Many would agree to do it, but then chicken out at the last second when they hear whispers that all who participate would be terminated for "job abandonment".
Many young pharmacists have too much debt to walk away.
Many pharmacists would say "it's not my fight. I have my patients to take care of and I have to put their needs first."
The problem is that THESE are exactly the pharmacists who need to join us. Wherever there is someone else who will "just do it", we have no collective voice. We have no unity. This is precisely why a union will not work. This is why a day of work boycotting will not accomplish anything other than job creation for new grads.
Another issue that surfaced recently was from a technician who was followed to her car by a patient whose CII was not fillable. It had been postdated by 2 days. The DEA is clear that you canNOT change the date of issuance of a CII prescription. Instead of the pharmacist making this clear to the patient, ambiguity ensued as he offered to call the physician, whose office had just closed. WE can NOT change the date. Why offer? Because we are trying to do the right thing? How about the legal thing instead? Sending this patient on his way would not have endangered his technician. WE are making OUR lives harder.