How to Complain

People complain.

Pharmacy patients complain a lot. At least it seems that way. 

Companies don't like complaints. Instead of using them as a tool to make positive changes in their business, they chastise the pharmacy team for not meeting the ridiculous expectations placed upon them. On my day off I ran into a former patient of mine. She was fired up and wanted to complain about the pharmacy she was currently using. As I listened to her, I realised we in pharmacy should guide our complaints. I could have told her not to complain but that wouldn't help. I could have told her to just call the 1-800# and allow the pharmacy to get in trouble. Instead, I opted for the third option: tell her how to complain. 

When patients complain, it is often a knee-jerk reaction to a perceived slight or overreaction to something that, had they taken time to breathe, may not have resulted in a complaint. In order to garner the appropriate response from the powers-that-be, we need to encourage the use of buzzwords. Without these, the corporate suits won't pay attention. Simply mentioning "metrics", "quotas", "HIPAA", or "privacy violation" will prick the ears of even the most inattentive corporate lackeys. 

Dear Pharmacy Gurus, 

It is with a solemn heart that I must call today for I wish to register a complaint. While the store where I shopped is the offender, I wish no repercussions to come to the staff there. They are only doing what is expected of them and therein lies the problem. First, you as company overlords are forcing them to meet quotas for vaccines. As a result, my pharmacy felt it necessary to run vaccine prescriptions through my insurance while filling my other prescriptions. While I am certain they intended to tell me what was and was not covered at the checkout window, this did not occur. It was not until I got home that I noticed the notes from my insurance company rejecting the flu shot, pneumonia shot, and shingles shot. If you did not place quotas or mandatory requirements on these pharmacies, this would not have happened. They also would have had the time to talk with me as I paid for my prescriptions. It is a sloppy, unprofessional way to drive business and I believe, unethical, which leads to my second complaint. 

If your pharmacies are engaging in this type of behaviour simply to meet your targets, is my privacy at risk? I believe that submitting a claim to my insurance without my permission is a HIPAA violation. Why? How? I haven't authorised you to bill them. I haven't okayed any claims other than the original reason for my visit today. I am disgusted with how you have taken this trusted interaction with healthcare professionals and turned it into a "do-you-want-fries-with-that?", cheap money-making ploy. Please remove quotas and metrics from your staff so they can get back to what they are supposed to be doing: providing me quality healthcare.
p.s. I think I'll follow up on that HIPAA thing. 

Ratings System

Retailers offer customers the option to write product reviews on their websites.

I like to research these before I buy something so I know what to expect. The ones that amuse me the most are the negative reviews. Obviously, if a product has many negative reviews, there must be a reason; it's likely an inferior product. What about the 1 or 2 negative reviews adrift in a sea of positives? 

Some common ones I found this weekend:

"I gave this a 1 because I couldn't figure out how to assemble it. I had to return it to the store." 

"The colour didn't match when I got it home." 

I think we need a system like this for pharmacies. Remove the fake, forced "Customer Service Reviews" and offer online reviews of your experience. This would apply not only to the pharmacy itself, but to the medications dispensed. 

"I gave this pharmacy a 1 because I had to wait in line behind 3 other people picking up their prescriptions and no one gave me a gift card."

"The drive-thru wasn't fast enough. I should be able to order and pay at 1 window then pick it up immediately at the second window like I do with my breakfast, lunch, and dinner every day."

"The blue ones worked better and they gave me white ones."

"The pharmacist was so busy helping someone find something out front that I had to wait an extra 2 minutes to get my prescription checked. The customer service is horrible."

Perhaps we could set up a website dedicated to Pharmacy reviews?
We could offer a drop-down menu of all pharmacies in the country and sort by store number or address.  This would allow patients to go online and rate their service. Instead of a phony "On a scale of 1 to 5, How was your service?" we could see that the patient was unhappy with the fact that we stapled her bag shut. It happens. We shouldn't get dinged on "satisfaction results" simply because she gave us a "1" for a staple. It's all about context. This way we can hand the patients the address at pickup, or text them a link, then find our own store on the list.

Maybe we could include a corporate link too?

Anyone want to start this with me? We can link it to my page.
"Pharmacy Patient Reviews"?

English is Funny

We Americans have a way with words. We can take anything another country or another part of our country has and twist it, chew it up, and spit it into a new, bastardized creation. It's our specialty.

From the South to New England, from the inner city to open country, it can be difficult to understand other fellow Americans. 

Birth Control Language Barrier: 

BeYaz or Not Be Yaz, that is the question...

Female That Wants Birth Control: I need my pills refilled. 

CP: Okay. Which ones? 

FTWBC: The birth control. 

CP: Do you know the name? 

FTWBC: It BeYaz

CP: Okay. Um. Is it YAZ? or is it BEyaz? 

FTWBC: I said it Be Yaz

CP: Okay. Let's try it this way. Be it Yaz or Be it Beyaz? 

FTWBC: Right. 

CP: What's right? 

FTWBC: Be Yaz. 

CP: It is for BEYaz? 

FTWBC: That's what I said. 

CP: <looks in computer. it's Yaz.> 

Now just imagine this not as a patient calling in for a refill but as a representative of the prescriber's office calling in a new prescription.  

Set up for Failure

What are your company's expectations? "Unrealistic" should be the answer no matter what number you give. Let's examine flu shot goals, um targets, I mean quotas, er, plans. Math is good here.
Here is an example of averages in statistics: On average, 55-60% of the US population votes in presidential elections. The numbers vary little from elections after 1920 going as low as 49% to a high of 63%. It is fairly accurate to say voter turnout is ~57% every year since 1920.

As it regards pharmacy, let's assume the following:

On average, 40% of the US population receives a flu shot each year. The numbers vary little year to year. This is, for all intents and purposes, a finite number. (And the number of the counting shall be 40%. No more. No less.)
Your company expects an increase of 20-60% in the number of flu shots administered by your store.
Where will we get these shots?
Ten years ago when I first started immunizing, it was easy to show growth. I was the only person in town giving shots. It stayed that way for 4 years. Then everyone got in the game. Now you can receive a flu shot from your prescriber, an urgent care clinic, in hospital, during an ER visit, from the fire department, at the county health department, any pharmacy on any corner in any town, or during any vaccination clinic provided by any of these groups.

Another number to add to the equation: Prescription Growth. Each year we are given metrics, um targets to reach as it pertains to prescription growth. I have yet to work in an existing (not new construction) store that had a goal of 20-60% growth in prescriptions. Usually these goals are single digits, but always much less than 20%.

As I understand it, corporate people want us to grow one segment of the business by 40% in a saturated market where growth is stagnant and our overall prescription increase, the bulk of our business, is only expected to grow by <10%?

Where do we get the flu shot business? We are expected to steal, pilfer, and swipe it from competitors. Guess what? They have the same unrealistic, unattainable goals as we have. While we may not lose business over this, we are certainly not going to gain 40% either.

NPR

Pharmacies have no control over the prices of prescriptions where patients use their insurance. Period.

(For the NPR article I am referencing, click here: http://www.npr.org/sections/health-shots/2015/09/16/440612238/how-to-save-money-on-prescription-drugs-insured-or-not?utm_source=facebook.com&utm_medium=social&utm_campaign=npr&utm_term=nprnews&utm_content=20150916 )

A pharmacy cannot charge more than its Usual and Customary Charge to a patient on insurance. This means that if the cash (no insurance) paying patient is charged $45, the pharmacy cannot charge her $900 on her insurance. Many pharmacies when quoting prices, are only able to give straight cash prices and not prices on insurance without first billing the prescription to the insurance. Some companies are able to provide these prices but you must make sure what price you are receiving. A better solution would be for the patient to call her insurance and ask them. They are the ones that set the prices.

Lesson 1. Pharmacies want to build loyalty. We are a most-trusted profession. The correct response to pricing issues would be build a relationship with your PHARMACIST first. Second, READ YOUR INSURANCE EXPLANATION OF BENEFITS. If your insurance selected a preferred pharmacy, go there. If you like your pharmacist and she does not work there, pay more for her knowledge and trust. If it is cheaper to purchase 90 days at a time, ask your prescriber to write new prescriptions that way the next time you see her. (NPR got this a little wrong. You won't be avoiding copays. You'll have to pay more initially. If your copay is $30.00 for one month, it's usually $90.00 for 3 months. Generally, the only way to save copays is to use mail order which often fills 3 months for 2 copays.)
Again, trust your pharmacist. Ask her what alternatives are available. Go home and check your EOB or your insurance's online formulary (or call them) and research which of these alternatives is preferred. Call your prescriber and ask her to change it.

Lesson 2. Appeal. Good idea. But the problem is this relies on the patient actually taking control of her own healthcare. It is easier to have the pharmacy and prescriber's office do all the work than to take some responsibility.

Lesson 3. Look for Financial Assistance. Another good idea. Another problem with patients taking responsibility. The patient would have to do the research.

Lesson 4. Bad idea. This requires no effort on the part of the patient which is why it's the easiest and least effective.
Discount Cards are NOT helpful. They cannot be combined with commercial insurance.
They are a data collection scam. People who complain about privacy violations seem all too willing to let these companies have access to their personal information in exchange for an average of 10-20% off the cost of their prescriptions. If these patients are truly cash paying customers, then, and only then, should they work to find a lower cash price. Call other pharmacies for prices. Ask about their in-house discount cards. Ask if your regular pharmacy matches competitor prices. This is especially relevant when purchasing medications for pets.
(Chain pharmacies often do not have access to Acquisition Cost which is the price actually paid for the medication. Independents do. They will be better able to give you a better deal because they can see how much they need to charge to cover their costs. Chains generally only see Average Wholesale Price which can be hundreds of dollars more than the AC.)
Example: The anti nausea medication Ondansetron has an AWP of ~$700 but an AC of closer to $4.00.

Manufacturer Cards (Note: These are different from Discount Cards.) They are distributed directly by the manufacturer and are specific to their medications. They are for brand name medications as a way to reduce copays but, as correctly stated by NPR, they cannot be combined with Medicare plans or government-funded plans. Unfortunately, prescribers continue to hand these cards out to these patients.

Lesson 5. Great idea. We have been saying this for years. The only problem is it requires research by the patient. It is difficult to understand, especially for older patients on Medicare who take multiple medications, often many brands and generics. Ask your pharmacist for help before making a final decision. She can help.

Unfortunately, NPR set this up so the pharmacist looks like the bad girl. The easiest lessons are the ones over which we have no control and are the ones the patients would rather do. Because the best ideas require the most work from the patients themselves and are the most effective, few will opt for this route. We will still get yelled at and patients won't listen as we offer them alternatives.
C'est la vie...

Apple

After spending some quality time this past weekend at my local Apple store, I realized what an amazing concept they have for their retail outlets. I think I want to work with them on designing a pharmacy.
A technician will greet you as you enter the store. She will ask the reason for your visit today then direct you to the appropriate person/area of the store while entering your personal and insurance information on an iDevice and alerting that person to your needs.

Second person will instantly know why you are here-to pick up a prescription, to drop off a prescription, to have us check your insurance, to get a flu shot, for counseling, etc. She will guide you to the appropriate table/counter/area where a technician will answer all your questions and assist you with your needs that day. The pharmacists will be behind a counter/wall checking your prescriptions as the orders appear but will walk them out and review them with you. A technician/cashier with another iDevice will scan your credit card for payment and have you sign, with your finger, right on this device and your transaction will be complete.

Vaccines

Arguments to not get a flu shot (or any vaccine).
1. I've never had a flu shot and I've never gotten the flu so I'm not going to start now.
(Have you ever been in a car accident? No? Better cancel your car insurance. What a waste of money.  Ever had a homeowner's claim? No? Cancel that policy as well.)

2. The flu shot gives me the flu.
NOPE. You may have experienced flu-like symptoms, but you certainly did not suffer from the flu. You'd know it if you did. Let's put this in perspective. Riding your bicycle into the back of your own parked vehicle, in your own garage is not a car accident any more than 24 hours of runny nose, diarrhea, or headache is "THE FLU". Getting hit by a semi while riding your bicycle down the middle of the street? Now that's the flu. It will take you weeks to recover or, if you're really old or very young, there's a good chance you're dead.

3. Big Pharma!
What? That's it? Then I shall make sure to not fill your Prozac and Antibiotics and Synthroid anymore. I never knew you felt so strongly about prescription medications.

4. It's not 100% effective. They're just guessing.
Yet you keep taking your paycheck and dumping it in the Instant Lotto machine at the front of my store every week.

5. It's government population control!
Agreed. The more people rail against vaccines, the less people will get them. The fewer people that get them, the more people will die from vaccine-preventable illnesses. It's just a really, really long-term plan.

Rules for Offices

1. If a pharmacist is calling, you can bet it is for a valid reason. Treat it as such and listen to her.
2. Do not send an e-rx to cancel an e-rx.
3. Do not leave a voicemail to cancel an e-rx.
4. Not all faxes are refill requests. Read them before trashing them or sending them back with a signature.
5. Identify yourself. Name, rank, serial number. That way I know how to escalate my call to the proper party if required.
6. Enunciation. It has 5 syllables. You must be able to say that word so I can understand it before calling in any prescriptions to me. If I can't understand it, I didn't receive it.
7. Proofread. It's most likely the prescriber who entered the e-rx. Do him the proper courtesy of a read through before hitting "send". You'll make him look good and me love you long time.
8. Don't tell people prices and don't let your prescribers tell people prices.
9. Don't tell people "it will be there when you get to the pharmacy". People will hear that as "it will be READY" and get mad at us when it isn't.
10. When I say there is a problem with the electronic prescription I just received, do not read it to me. It didn't come across blurry. It wasn't hard to read. If I wanted it read to me, I'd call Morgan Freeman because that man can narrate. I want the incomprehensible mumbo jumbo you entered to become a coherent, intelligible script so get me the person who can fix it.
11. Talk to your prescribers. Tell them what mistakes they are making. If they don't know we are calling asking you to fix their mistakes, they will continue making the same mistakes. This means I have to keep calling you. This becomes frustrating for us both.
12. Don't leave me a voicemail when I had to leave you a voicemail because I needed clarification. More often than not you will not completely answer my question, necessitating further calls from me to you. This becomes frustrating for us both.
13. When we call on the same mistake each month, fix it in the system. Your prescribers are lazy and simply approve what the patient had last time. Too bad we called and no one fixed it. Don't know who is more at fault, you for not fixing it or the prescriber for blindly approving error-filled fills month after month. This becomes frustrating for us both.
14. Whatever you are chewing, sucking, or masticating, spit it out before talking to me. I'm not going to play the "guess what I have in my mouth" game with you.
15. If I ask you for information, believe that I need it. Just because your prescribers do not know or understand the rules and laws that apply to them and did not properly train you, their staff, on them, does not mean that I don't need a DEA#, CTP#, or NPI#. Which leads me to...
16. Do not tell me I am the only pharmacy/pharmacist that "bothers" you with these trivial nuisances. Pretty certain I am not the only pharmacist in the country who worked hard for a license and would like to retain it for its awesome money-earning potential.
17. Finally...if I tell you it isn't here, if I tell you I didn't receive it, if I tell you it's not on my voicemail, it's not on my fax machine (yes, I checked the paper tray), it's not in my e-script queue, it's not yet been received anywhere in my system, keep in mind we have a patient waiting. Give me the prescription now. Give it as a verbal or resend the e-script. I don't care. We can argue later about where it went and why your screen confirms it was sent. I have you on the phone right now with a patient waiting. Give it to me, then research it. I'll probably have to call another pharmacy to have them reverse it anyway.

But I'm a Prescriber

There are no more powerful words in the English Language than these.

It is the fix-it-all answer for any situation. 

CP: There's a problem with this prescription you wrote. 

Good Ole Doctor: But I'm a prescriber. 

CP: Your car ran out of gas. 

GOD: But I'm a prescriber. 

CP: You have a small penis. 

GOD: But I'm a prescriber. 

CP: I'm trying to explain why you're wrong. 

GOD: But I'm a prescriber. 

You get the picture. This would not be so bad if the following events had not taken place. 

CP: You can only get one inhaler. 

GOD: But I'm a prescriber. I write it like this all the time. 

CP: Good. So you understand that just because you write it like that does not mean they actually get it filled like that. 

GOD: But we need one for home and one for school. 

CP: And the insurance only allows one at a time. Picture this. Let's pretend that you're a prescriber...

GOD: But I'm a Prescriber. 

CP: Good. So stay with me. As a prescriber you know that you can write for whatever you want, let's say 90 days of HCTZ 25mg. The insurance...

GOD: But I'm a prescriber. I know what you're trying to say and I get it. 

CP: I don't think you do because you keep interrupting me. As I was saying...

GOD: But I'm a prescriber and we need one for home and one for school. 

CP: Okay. Let's try this. Let's pretend it's NOT the first day of school. Your insurance only pays for one inhaler because, per the directions, this one inhaler is a 25 day supply. This means you can only get one filled per month...You can refill it...

GOD: But I'm a prescriber. I know this. Just tell me when I can get another one. 

CP: As I was saying...most likely, you can get it in 17 days. 

GOD: And it will be free, right? 

CP: Wait what? Why free? 

GOD: Because it's the rest of what was written. I shouldn't have to pay another copay because you can't fill the whole thing today. 

CP: How does that even begin to make sense? 

GOD: But I'm a prescriber. I know these things. 

CP: Obviously not a good one and obviously you don't. Back to the 90 day thing. You can write for whatever you want. It does not mean the insurance has to pay for it. If they limit you to 30 days, you don't come back and get the next 2 months for free. 

GOD: But I'm a prescriber. Of course what you are saying makes no sense to me. You are the fool. Just tell me what I need to do to get my child's inhalers filled. 

CP: I tried but you kept interrupting me. 

GOD: I'll just call my coworker and have her send a new one for two inhalers. 

CP: Fine. As long as it meets the criteria for payment from the insurance or we will be back to the top of this dialogue and I don't think you want to try this again. It will end poorly for you. 

GOD: But I'm a prescriber. 

Open at the Close

Signs are only helpful if two requirements are met:
1. You must be looking for them.
2. You must read them.
There are other factors that enter into it of course but without these two, the rest of them are moot.
(You must be able to interpret them. You must pay attention to them. You must heed them...etc.)

We have our hours conspicuously posted:
a. on the front doors
b. on the pharmacy counters
c. on the wall of the pharmacy
d. in the waiting area
e. drive-thru windows

The problem with arriving early to work is people can see you. Even if you have shutters instead of a gate, people see the lights on and know someone is home. They'll just bang on the shutters shouting "I know you're in there. I just have a question!" until your blood boils.

Here is last week's verbal sparring joust:
<We are early. It's a Saturday. Unpacking the crew's donuts and coffee. Sunny. 78 degrees...inside and out...>

Early Ass Talker Making Exclamations: What time do you open?
CP: We open at 9am, kind sir. About 20 minutes.
EATME: It's 14 minutes.
CP: What?
EATME: It's 14 minutes.
CP: Well my clock says it is 8:43 so that's 17 minutes. (Which is also "ABOUT 20 minutes".)
EATME: Mine says 14 minutes.
CP: Glad I don't use your clock to open, then, huh? Perhaps you should sync your watch with my clock. This way you will always know when we are open and never be too early.
EATME: Smart Ass.
CP: Smart Ass who fills your prescriptions when we open at 9am. Which is now 16 minutes away. Provided I open on time. Sometimes people talk to me and keep me from getting my work done and I lose track of time. Glad you're here though so I won't forget.
EATME: I'll be back.
CP: In 15 minutes...give or take.
EATME: Can you take my prescriptions now?
CP: Are we open?
EATME: You're in there.
CP: And you're out there. What conversation would you be having right now were I not in here? Had I not decided to arrive early? What if I had been that pharmacist who believes in only working the exact 10 hours, 600 minutes since you're counting, and not a second more than scheduled?
EATME: Piss off.
CP: I don't get to do that in a 10 hour shift. See you in, hey! look! it's now 14 minutes.

Disney's 3:00 Parade Question

Little Old Lady: My doctor gave me these patches. Which side do I use?
CP: The sticky one.

Every business should work to discover what their "What time is the 3:00 Parade?" question is. From this, they should teach their employees to learn what the inquirer meant to ask instead of giving them the straightforward, "you're an idiot" answer. For the Disney example, the takeaway is that people are actually asking "What time will the parade pass by here?" or "When will it enter Frontierland?" since that is where they are heading next.

I thought of this as my intern dutifully told me about LOL's question and I was about to answer her call.
What was she trying to ask?
She obviously had never used transdermal patches before.
What did the patches look like?
Was she going to ask where to put them?
Was she concerned about side effects?
Did she read the package insert?
Why, when she was at the counter and offered counseling, did she not ask then and there so I could open the box and show her?
How do I answer this over the phone?

LOL: Which side do I use?
CP: Which side is sticky?
LOL: There isn't one. There is a silver side and a clear plastic side. There's also this tape cover thingy in case I think it won't stick. Do I tape it on with that?
CP: No. Since I can't look at one right now, let me ask you: Does the clear side look as if it peels off?
LOL: It does.
CP: Good. Lay the patch flat on the counter, slowly peel the backing from one corner to keep it from curling, then once it's removed, place it in the desired location on your body. Press the patch into place starting in the center then working out to the edges to make sure it is completely stuck in place. If you're worried about showers or swimming with the patch in place, you may use the cover. Always remember to remove the old patch before placing another patch anywhere on your body.
LOL: That makes more sense now. I read all the directions but they didn't say which side to use.
CP: That's why we are here. To help. Remember, there are no stupid questions, only stupid directions.