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Thursday, April 30, 2015

License Required

There should be some sort of law, mayhap a requirement that the people who write prescriptions for medications should be trained and licensed.
I believe they should have to go to school.
I believe there should be some sort of apprenticeship or internship, or residency requirement.
I believe there should be a battery of tests they need to pass before said licensure.
I believe there should be required studies, especially focusing on the medications that will be prescribed and the laws governing how to prescribe.
I believe they need to show proficiency in all these areas before being granted a license.
I believe they should, once granted a license, be required to stay current with mandatory continuing education and board examinations.

I believe...what's that?...they DO have all those requirements? Then how can you explain this conversation with a Delightful Office Lady?

CP: Go for El Pharmacisto.
DOL: Is this the pharmacist?
CP: Ja. For sure. I am Inge from Sweden.
DOL: What?
CP: Never mind. How may I serve you, DOL?
DOL: I work at Dr. Zoffis and he is trying to prescribe something and we can't find it in our EMR.
CP: First, allow me to thank you for calling me. I cannot tell you how grateful I am when offices call to make sure they are sending electronic prescriptions correctly. It is much easier than relying on me to just fix whatever you sent. What is your question today, DOL?
DOL: "Doctor is trying to prescribe INTUNIV for a patient."
CP: Okay. That's pretty easy.
DOL: "But he wants the NON-ER version. He can only find the ER version in our system."
CP: Um. That's because Intuniv is an ER product. That is the design of THAT brand name.
DOL: "Can I just call in the non-ER?"
CP: You're serious? No you can't just make up a drug that doesn't exist just because Herr Prescriber wants it.
DOL: What should I tell him?
CP: He can prescribe Tenex which is the same drug, guanfacine, which is not extended release. It only comes in 1mg and 2mg though. Is that what he wants?
DOL: No. He says he wants Intuniv.
CP: He's a pediatrician?
DOL: Yes.
CP: Did he go to medical school?
DOL: Yes.
CP: Okay. Tell him he either needs to retire, or to drop his license in the mail and send it back to the Board then take a long vacation.

<3 hours and 11 minutes later>
CP: Surprise, surprise, surprise. Here's an e-script for Intuniv.

Tuesday, April 21, 2015

Stupid is as Stupid Does…

Some say the end is near. Some say we'll see Armageddon soon. I certainly hope we will. I sure could use a vacation from this bullshit, 3-ring circus sideshow of freaks here... The only way to fix it is to flush it all away…

CP: Here's a prescription to check.
CP's Partner: Why is it on hold? It's an antibiotic.
CP: Check the profile.
CPP: This is already in our bagged and tagged section?
CP: Yep. Been there for a week.
CPP: Despite 4 phone calls, 20 text alerts, and 15 tweets reminding him to come get it?
CP: Yes.
CPP: Why did they call it in again today?
CP: Let's play pretend. You pretend to be Dr. Zoffis and I'll play the silly patient.
CPP: Okay.

CP (as Silly Patient): I'm not feeling well.
CPP: (as the dashing Dr. Zoffis): Poor baby. What's wrong? Didn't we just see you last week?
CPSP: Yes. But I'm not feeling any better.
CPPDZ: Why not?
CPSP: I'm not sure.
CPPDZ: Let me call in another prescription for you.
CPSP: Okay. If you think it will help.
CPPDZ: You call and let me know if you don't feel any better after I call this in for you.

CPP: That was phun.
CP: Pretty sure that's how it had to play out. No other explanation is plausible. Apparently SP missed the part about actually coming to the pharmacy, retrieving the prescription, then taking it into his body via the oral route.
CPP: Mayhap Dr. Zoffis should have asked if the patient had actually taken the first round of antibiotics that he prescribed?
CP and CPP: <fall onto floor in fit of sidesplitting laughter>
CP: I haven't laughed that hard in a long time.
CPP: This would be like calling the garage about your leaking tires to complain they are losing air, scheduling an appointment, not showing, then calling again every day saying your tires are getting flatter and you can't understand why.
CP: Better yet. That'd be like going to a restaurant, ordering food, not eating any victuals, then ordering more food, continuing not to touch the tastiness before you, then wondering why your hunger continues to grow.

Monday, April 20, 2015

Expectation Vs. Reality

I have written, often, about how patients' expectations reside outside the realm of reality; so much so that expectations and reality actually conflict with each other. With that in mind, I have decided to create a business model for pharmacy. I am going to open a group of pharmacies that exist outside reality. In order to survive in a crowded marketplace where competition is fierce, one must change the game. You must be able to adapt to the finicky needs of your clientele. Discounted Unrealistic Patient Expectation Drugstores will cater to the modern-day patient.

DUPED will offer the following services and modern-day amenities unavailable anywhere:
1. Label-Slapping Only Lines: If your prescription is for a medication that comes in a box or unit-of-use package (Medrol Dose Pack, Z-Pak, Eye/Ear Drops, et al.) then step right up. Simply show us your prescription and we will grab a label from under the counter, turn around, grab your box and slap that bitch hard! Move along.

2. No counters: We will have floor-to-ceiling glass walls separating us from the public. This way, people can watch our every move…which means I now have to wear pants.

3. It's Free!: Unhappy with your copay? Confused about which pharmacy you are actual standing in at this moment? Simply invoke the "I thought it was free…" clause and we will waive your copay. After all, our whore profession has bestowed upon everyone this welfare mentality.

4. No Prescription Required: Was your prescription supposedly sent by your prescriber? Did you "watch him hit the 'enter' key"? Did she say it'd be ready when you got here? No matter. Simply tell us what you think you were prescribed and we will make it happen for you. If you're really lucky, you'll be able to sidle on down to the "Label-Slapping Only" line for faster service.

5. Instant Refills: No refills on your prescriptions? We are supposed to call/fax/email your prescriber for renewals? Not a problem here at DUPED. Step right into this line and, with the push of a button, the click of a mouse, and the flick of the wrist with my magic wand, PRESTO! your bottles will be automatically refilled. Of course there will be that little matter of paying for an office visit (Provider Status and all that stuff).

6. Questions Only: For those of you who cannot be bothered with waiting in lines, or for those who like to push to the front to "just ask a quick question", we will install special (mega)phones throughout the store for you. Like the price checker machines located in many retailers, these phones will enable you to walk right up, pick up the receiver, randomly shout your question, and have it be heard only through the Bose speaker system placed directly in the pharmacy. Do not worry about pestering us with simple queries such as "where is the bathroom?" or "where are the shoelaces?" for our staff is completely knowledgeable and trained in the location of everything in the entire store.

7. Bathrooms: Since the number one question we receive is about where to go number two, we will install bathrooms at all 4 corners of the store, on both sides of the entrance, in the dead center of the store, and on either side of the pharmacy. People will still miss them despite the neon arrows flashing overhead to alert them, but we hope to save you time.

8. Wait Times: These are a thing of the past here at DUPED. We will no longer tell you a time to come back for your prescription. With the multiple lanes available for your convenience and the clear glass walls separating the staff from the patients, you can follow your prescription as it wends its way through all the processing steps involved in its production. Think of a cross between Subway and a luggage sorting machine at LAX.

Thank you for your time and we look forward to servicing you. We will not have customer satisfaction surveys, but we hope you will tell all your friends you have been DUPED.

Friday, April 17, 2015

Prescription Philling A la Carte

A Conversation with myself...
Me, Myself, and I: Welcome to Professional Label Slappers Anonymous. What brings you here today?
CP: I believe that we need to change the way we get reimbursed. We need to change the way we charge for prescriptions.
MMI: Just how would you accomplish this?
CP: We need to set up a menu. Something like a fast food's dollar menu.
MMI: Okay…Curious to see where this goes. Explain.
CP: There will be two sides to the board: FAST and ACCURATE.
On the FAST side, we will offer the following options:
1. selection of A medication, not necessarily the one prescribed for you.
2. professionally applied (read: slapped) label.
3. immediate checkout where you will pay AWP Plus $250.00
4. one signature to receive your prescription (which absolves the pharmacy of any liability).
MMI: Why so much?
CP: Convenience charge. Plus it pays for the lawyers.
MMI: Okay. What does the ACCURATE side get me?
CP: It's not what you think. For those that still want something quick and easy, we offer similar pricing. We still charge AWP PLUS $250.00.
MMI: How can you justify that?
CP: Simple. You ask for a prescription where all I do is "slap a label on it" or "dump pills in a little bottle". I can do that quite easily. Hence the reason we offer option #1-Fast. BUT…if you want me to put the correct information on the label, like your name, correct medication, strength, quantity, directions, refills, prescriber, etc. then that will cost you. If you wish me to check for interactions, make sure your prescriber isn't trying to kill you with poor penmanship or computer skills, or to check your allergies for you, then it will cost you.
MMI: I thought this was going to be less expensive. Why do you keep adding charges?
CP: Because the final step on the ACCURATE side is Billing Your Insurance. Once we bill your insurance, you will have a more acceptable, possibly, copay.
MMI: I see.
CP: Now all I have to do is bring this to everyone and let the (m)asses see it.
MMI: Insurances won't go for that.
CP: But they should. Imagine billing everything a la carte. For every part of the process, we are allowed to bill. Like prescribers and hospitals where every person that touches a patient gets to bill the insurance, there would be billing codes for each part of the prescription. Bottle, label, directions, DUR checks, tech time for data entry, tech time for filling, pharmacist verification--all billable.
MMI: You know they'd set limits, right?
CP: Yep. To the $10 minimum cost to fill a prescription with no drug in it, MINUS 20%, PLUS a $0.25 dispensing fee.
MMI: If you're lucky.

Tuesday, April 14, 2015

Pick Your Patients

We had a wonderful mother come into our pharmacy the other night. Her preferred pharmacy was too far and we are located just a mile or two from her homestead. She required a prescription that would need filled multiple times per month and the long commute to preferred location would be more expensive and frustrating to make for an entire year. She asked if we could help her. We did. We offered options for her. She "bothered" us with some OTC questions while we were finishing her prescriptions. She asked a couple more questions, thanked us profusely, and individually, as she left and that was how our night ended…

…and we got to wondering: Why can't we have all our patients be like her? We should be able to have a draft for patients every year.

If insurances can dictate which pharmacies patients may use, the pharmacies should be able to exercise the same right. We would send letters to patients in May/June announcing which pharmacy drafted them for the next calendar year/season which runs July 1st through June 30th.

CP's Pharmacy selected you to represent their team in this year's All County Phantasy Pharmacy season.
Walgreen's would like to welcome you to its 2015-2016 team. Congratulations!
CVS took Extra Care in choosing YOU for their 2015-2016 roster. Welcome aboard!
Rite Aid says you have the Rite Stuff to be part of their 2015-2016 Wellness+ Patient Panel!
WalMart wanted you for their 2015-2016 Wellness Plan! Here's your blue replica smock.
Target tapped you to be part of the 2015-2016 RedCards.

Each pharmacy would get to keep up to a certain percent of their current patients each season. As with all drafts, there are some risks involved. Those late-round picks can either score big for you or be a total bust, filling no prescriptions or being horrible patients. There would also be a period of free agency where patients could try out other pharmacies. Patients could ask for their release from their pharmacy while they also may be traded between pharmacies. This would help offset any losses due to moving or insurance changes. Patients would have to clear waivers if they were released locally whether due to insurance changes or relocation.

It would certainly help with "customer service" and inventory as you will always know who is coming in for what for the entire year. Imagine the inventory and budget control you'd have!

Monday, April 13, 2015

Worth A(nother) Shot

7. Payroll: (People who can't understand why we cannot give them 90 days on prescriptions written for 30 days with 11 refills.) Call your HR department and ask them to change your checks for you. You are paid $20.00 an hour and you are paid once a week. Ask if they will change it so you make $80.00 an hour for one week each month so you don't have to cash as many checks. It's the same thing, right?

8. Grocery Store: I was making breakfast this morning and I dropped a few eggs on the floor. I need them to finish my poached eggs and french toast. Can you just pull 3 eggs out of a carton and leave them at customer service? I'm on my way there right now.

9. DMV: Why didn't you call to tell me my tags had expired? You sent me a letter? I don't read that crap. I don't have time. Can't you just automatically renew them for me? Don't you have one of those Courtesy Renewal programs? The car dealer I bought my car from said I'd be driving this car for the next 10 years. I guess I'll just get pulled over and ticketed and it'll all be your fault.

10. Law Enforcement: "Do you know why I pulled you over? Your license tags are expired." Why do I have to renew them every year? I'm driving the same car. Nothing's changed. I have the same license plates I've had for years. No one told me they expire. Can't you call the DMV and get them renewed for me? They issued it the last time. They have all my information. It's not my job to get my tags renewed for my car. I guess I'll just crash without them.

11. Pizza Shop: When I go in to pick up my order and they ask how many pizzas and 2-litres, just to make sure the order is correct, I will yell and scream that I don't know. Someone else in the house placed the order and I'm just picking it up. It's your job to know what pizzas I take. I will then drive home and call back and yell that they forgot my Margherita Pizza and Garlic Parmesan wings which are what I wanted.

12. Dr. Zoffis: Next time I'm in the prescriber's office checking in, I am going to complain about everything they ask…"Can you verify your DOB?" It's in your computer! I've been coming here for years. I have an appointment. Don't you know who I am? New insurance? Yeah, but I don't have the card. Can't you just look it up? Preferred pharmacy? The one where I work! It's in the system. I was just here last week!

13. Liquor Store: You don't need to see my ID. I don't care if it is the law. I don't carry my license with me because I'm afraid someone will steal my wallet and take my identity. They let me buy it without a license last week when I was in here and they never card me at the ABC stores. You should have it on file from the last time. Can't you just look it up in "The System"?

14. Anyone: Why didn't you respond to my email? I just sent it. I watched myself hit "enter" and heard the "whoosh" as it got sent. Why haven't you responded yet? I need an answer now and you said you always check your email right away. I don't care that the phone was ringing as I sent the email. What's taking you so long?

If nothing else, pharmacy patients have taught me over the years it is much easier to fight and complain and yell and scream and get rewarded for bad behaviour than it is to just comply with what is being asked.

Friday, April 10, 2015

It's Worth a Shot

On my next day off, I am going to attempt to live one day as my pharmacy patients live theirs. I am going to pick one idea and practice it wherever I go that day. Any good idea needs scientific research to substantiate it. Patients' expectations should be no different. That means this Friday will be Practice Pharmacy Patient Practices and Postulate Possible Plausibility (P-6) Day.
I am going to model my study after the conversation I had on Monday: 

Unrealistic Expectations: "I dropped 1 of my Ramipril capsules in the toilet. Can you replace it for me?" (I know, first time for everything.) 
CP: No. That's not how it works. 
UE: "Well, it was worth a shot." 
CP: Not really. In what reality do you live? 

That's when I decided, maybe I've been doing it wrong all these years. Here's my plan: 
1. Grocery Store: I dropped my gallon of milk on the floor of my kitchen, you'll replace it, right?

2. Bank: I ran out of money in my account but I get paid next week. Can you just give me a few hundred dollars until then? I come here all the time.

3. Gas Station: I'm in town on a business trip and only need a few gallons to get back home. I don't want a full tank. Can't you just give me a few at no charge?

4. Movie Theatre: <buys ticket, watches movie> That wasn't the movie I wanted to see. Can I return my ticket and see another movie? OR I didn't like that movie. I didn't realise it had Tom Cruise in it. I want to watch another movie without him in it.

5. Restaurant: I am going to ask for "the usual". I come here every week and they know me. They will reply with, "Of Course, CP! We shall bring it post haste as we knew you were coming". Once the plate is presented to me, I shall call the maitre'd over to the table and loudly complain that I am no longer eating this. I changed my usual order yesterday and though I did not in any way communicate that decision to the loyal staff who know me so well, I fully expect them to return my plate of food, send me a new dinner with the correct order, pay for their mistake, and offer me free dessert and after dinner aperitifs.

6. Lowe's: I bought a ceiling fan here from you and I always get the 4 light bulbs replaced here. They all burn out at different times. Can you make it so they all burn out at the same time? I hate having to make multiple trips down here every couple years to just get one bulb.

Monday, April 6, 2015


To illustrate normal directions that, upon closer inspection, are unnecessarily long or redundant, I offer the following:

1. Zithromax Z-Pak--"Take according to package directions…until gone."
Okay, if they take it according to the directions, it will be all gone.

"Under redundant in the dictionary, it says 'see redundant'". (Robin Williams)

2. Prednisone Tapers and Medrol Dose Packs that end with "…THEN STOP or D/C".
If you give a patient exactly enough tablets to last the course, which the majority of these do, then on the last day, they will take their last tablet. Is it truly necessary to state "then stop"? Should it not be quite obvious? Even taking into account the Stupidity Curve, I have yet to receive a phone call that goes like this:

CP: How may I help you?
Taper Taker: I have a question about my steroid.
CP: Okay.
TT: It said to take 4 for 3 days, then 3 for 3 days, then 2 for 3 days, then 1 for 3 days.
CP: Okay. That's a statement, not a question.
TT: I received 30 tablets.
CP: Again, statement.
TT: Well it's been 12 days and I took them all.
CP: You're getting there. I can almost hear the inflection that alerts me to an audible question mark.
TT: What do I do now?
CP: What do you mean?
TT: I followed the directions for 12 days. Now what do I do?
CP: Be well? Live long and prosper?
TT: I need direction in my life.
CP: Had I taken the time to put "THEN STOP" on your label, would that have been sufficient to prevent this call?
TT: Yes. Then I would have known exactly what to do.
CP: Okay. Please stop.
TT: The medication?
CP: No. Calling me.

My partner received a prescription for this same Prednisone taper while I happened to be cherry picking  the e-rx queue. Her directions ended up reading:
"Take 4 tabs for 3 days, then 3 tabs for 3 days, then 2 tabs for 3 days, then 1 tab for 3 days then stop taking because, quite frankly, you will be out of medication so even if there were more directions, you wouldn't have any medication left."