Professionally, No

Me: What conversation are we having today?

CP: A major pet peeve among pharmacy staff is when patients ask for refills by telling us to "just fill everything". 

Me: Agreed. Every time you write a post about patients and refills, this has to be the number one complaint. Why don't we like that again? 

CP: First, it's lazy. If you're too lazy to tell me which medications you are taking, too lazy to find the bottles in your house, too lazy to write down the numbers or names of the medication(s) you currently take, I'm too lazy to "just fill everything".

Me: Like you always say, I should not care more about your health than you do. 

CP: Right. 

Me: What else is wrong with the Customer Of the Day (COD) saying "just fill everything"?

CP: We could fill medications the patient no longer takes. We could fill old strengths, old combinations, or duplicate medications within a class. Maybe the patient had a reaction. Maybe a new prescriber changed therapies. Maybe they have some medications filled at another pharmacy in another form. The point is, we could contribute to medication mismanagement by just filling everything. It's our job to make sure their therapy is up-to-date. It's part of the CMR process for this reason. 

Me: In other words, it's professionally irresponsible to "just fill everything". 

CP: Succinctly stated. 

Me: Is there another part to this? 

CP: Yes. If the patient leaves with something they don't take, they'll ask to bring it back. If they don't leave with it, but notice they don't need it before they leave, we will have to put it back. Imagine the work involved if we filled an extra 2 prescriptions for every patient every day then had to return the same extra 2 prescriptions every day. It's not like we have anything better to do than undoing all our work. It's another reason #WhyYourPrescriptionTakesSoLong. 

Me: Got it. I have to ask. Why are we having this conversation? Usually you let people fight it out in the comments section of your posts. You rarely tackle the "just fill them all, let COD sort them out" issue directly. 

CP: The phone call I received recently. 

Me: Go on. 

CP: You agree that pharmacy staff everywhere despise the "just fill everything" mantra, yes? 

Me: Yes. They are very vocal in their opposition to this. 

CP: I received a phone call from a pharmacy to transfer prescriptions. 

Me: Okay. Normal. What's wrong with that? 

CP: I asked "how many" and was told "I'm not sure yet". Cute. But I knew where this was headed. 

Me: Let me guess, the pharmacist said "just fill everything"?

CP: Yes. The pharmacist, who likely loathes the "just fill everything" from his patients, told me the patient requested a transfer of "everything". 

Me: What did you do? 

CP: After madly cackling for nigh on a second then realising he was serious, I said "no". When he seemed stunned, I explained my reasoning. 

Me: You could have just transferred the whole profile. 

CP: True. I could have. In which case, again, I would have been performing needless work for a lazy patient who no longer wanted to be my patient. 

Me: <whispers> I can see why. 

CP: Shut it! Why would I waste my time, and the other pharmacist's time, to transfer prescriptions this feckless COD may not need? How far back do I go in the profile? Do I transfer the coochie cream from 6 months ago? Everything that is on hold and hasn't been filled over the last 6 months just in case the time is ripe to get that Belviq or Cialis filled? 

Me: I get it. What you're saying is pharmacists can't have it both ways. 

CP: Right. You can't complain about how patients act then encourage and engage in that same behaviour with another professional. 

Me: I see your point. 

CP: Thank you. Do you think others will? 

Me: Of course. 

CP: Thanks.

Me: You really need a verbal jousting partner, when CP's Partner isn't here.

CP: Intellectual intercourse? 

Me: Yes. 

CP: It's not my phault they keep cutting hours so I have to work just with you all night. 

Miscarriage of Duty

I have so many problems with this situation. Having been on both sides of the counter for this, I can sympathize with the mother and how poorly it was handled.

1. You're a pharmacist. You understand how these medications work. The woman was carrying a lifeless fetus in her womb. Whatever your personal beliefs about abortion, this is not killing a baby. She is inducing delivery of a deceased fetus. You are no more responsible for its death than the hotelier who gave a couple a room is responsible for them getting pregnant on one of his beds.

2. I know it's a "he said, she said" sort of situation but did the pharmacist really stand at the counter, prescription in hand, and refrain from giving it to her? If so, he's no colleague of mine and I'd be ashamed to call him one. Take her aside to explain it. Allow someone else to sell it to her. Under no circumstances should you explain it's for your own ethical reasons that you are denying the sale. I won't push my beliefs on you, you don't push them on me. That's how this played out in front of other patients. Yes. You are allowed to possess them. Yes. You, in Arizona, are allowed to deny the sale for this reason. However, your lack of empathy is uncalled for and galling. Call a pharmacy down the road and transfer it.

3. I do not agree with these "ethical, moral, religious" exemptions. If I believed the world was flat, I'd not take a job in a globe factory or store. (Is this the best analogy? No. It's lame, but it'll make people think a little about the inanity.) If you don't like vaginas, don't become a gynecologist. You don't get to pick and choose which medications you're going to dispense. An addict is dying in the street. Do you hand a box of Narcan over the counter to help save her and say "come back and we'll bill it later"? Do you hand a bottle of Nitroglycerin over to the wife of a man who is having chest pains out front? Definitely. Do you allow your beliefs to get in the way of saving someone's life? You cannot if you have any ethics at all.

4. When I was in my Ethics class in school, we had to watch these cheesy vignettes and determine if they were ethical responses from the pharmacist. The only one I remember was a man filling Estrogen for himself on his way to becoming a woman. The pharmacist looked at him and went "WHOA! NO way!" and handed it back. At the time, I remembered the Stone Temple Pilots song, Creep, and I said "It's not our decision. We have to let him become half the man he used to be". It's a legitimate prescription for a legitimate reason. While we may not agree with the intended use, there is nothing ethically wrong with it.

which leads me to. . .

5. "Arteaga filed a complaint with the Arizona State Board of Pharmacy. And, she wants a law in place that would require pharmacies to fill prescriptions approved by doctors." 
Whole buncha NOPE NOPE NOPE on this one. (If anyone wants to know why this is a bad idea, see "Opioid Crisis in America" and you'll learn what happens in these cases.) We are professionals. We are trained to use professional judgement. While I sympathize with her in this ordeal, there is no way in hell I am going to be a prescribers' bitch and fill whatever they write. That is not the job of the pharmacist. I can see it now:
"Sorry ma'am. Your prescriber is trying to kill you with this drug interaction but the law says I have to give it you and not question his almighty-ness."

To me this means she, like most of the general public, does not understand a damn thing about what our job is. We are more than just "pouring pills from big bottles into little bottles, label slapping, mindless automatons". When the social media outrage over this subsides, we will back in the shadows, doing our jobs of making sure your prescribers don't kill you. That you take the correct medications correctly.

Now that I think about it, I'm Batman.

https://www.khou.com/article/news/nation-world/walgreens-pharmacist-denies-pregnant-woman-miscarriage-medication-over-his-ethical-beliefs

Stop Messing Around

Bottle Looks Unfamiliar: You gave me the wrong medication.
CP: And Good Morning to you too.
BLU: Are you trying to kill me?
CP: I don't even know you. So, not yet. But keep it up and. . .
BLU: You gave me blue tablets.
CP: Okay. Are they making you sad because they're blue?
BLU: What? No! They're not working.
CP: That's hardly an attempt on your life.
BLU: I called my doctor and he said you must have given me a cheaper version.
CP: Well, he IS a doctor who does not work in my pharmacy so his expertise is unquestionable in this.
BLU: You're messing with people's lives here!
CP: Yes. Pharmacies are now conducting social experiments. How will patients respond if we switch from red to blue?
BLU: The green ones worked that I got last month! And the Nitroglycerin you gave me are not round like the ones I've been getting at CVS. I haven't slept in a week!
CP: So you had been getting your prescriptions at CVS and now you switched to me and because I dispensed a different manufacturer, I am messing with your life?
BLU: Yes.
CP: Curious line of thinking. Colour does not equal potency. I also could not explain to you that the colour had changed since I did not know what you received last month. You do have to expect that if you change pharmacies, other things will be different as well. I mean, the pharmacist was different too. Or did you not notice that?
BLU: But the colour is different and my doctor said you gave me cheaper stuff.
CP: Yes. Your doctor. Who knows less than nothing about what I do. Did you know your doctor buys his flu shots at the end of the purchasing season, after all the pharmacies? Know why? because he wants the cheapest stuff around. So make sure you don't get your flu shot from your doctor because he gives cheaper versions. His flu shots are probably blue too.
BLU: You don't know that.
CP: Any more than your doctor knows what I do.

Patients?

Someone asked me to answer the question of pharmacy visitors should be called: Patients or Customers. Simply put, here is my response. 

Patient: A person receiving or registered to receive medical treatment. (Yes)

Treatment: Medical care given to a patient for an illness or injury. (Yes)

Care: The provision of what is necessary for the health, welfare, maintenance, and protection of someone or something. (Yes)

Provision: The action of providing or supplying something for use. (Yes)

Customer: A person who buys goods or services from a shop or business. (No)

Goods: Merchandise or possessions. (No) 

Regardless of practise location, pharmacy visitors are patients. 

OTC as Rx?

I received a fax back from a prescriber's office last week with this note:
"Stop sending prior auth requests for meds patients can buy OTC."

To which I promptly replied:
"Stop sending Rxs for items patients can buy OTC."

The question often arises on pharmacy phorums about OTC products being prescribed and filled as prescriptions and a lengthy, often heated debate ensues. I often wonder why. Here is a discussion I recently had with myself playing Devil's Advocate with. . . well, myself.

CP: We get paid to fill prescriptions.
Me: But they're a pain in the ass.
CP: How, exactly?
Me: They're not in the computer.
CP: When was the last time we dispensed something that wasn't in the computer?
Me: I don't know. That's the typical counter argument.
CP: I can find an NDC made by Major or Rugby for almost every medication prescribed in our area.
Me: But they're not covered.
CP: Sure they are. Most Medicaid plans cover those NDCs in particular. Most commercial insurances do not, but I have had a few Medicare D plans pay as well.
Me: They're more expensive than the patient buying it OTC.
CP: Match the price.
Me: Too much work.
CP: Why?
Me: They. Can. Buy. It. O. T. C. and not bother me.
CP: They can. Maybe they don't need the whole box which will go to waste. Also, if we fill it as a prescription, it will have a label on it. The label will clearly instruct the patient how the prescriber wanted them to take it which may differ from the OTC package directions. In a week or a month when the patient has to take it again, where will the directions be? Which will they follow?
Me: They will have kept the instructions in the package, right?
CP: Sure. And I'm Batman.
Me: But we don't make money off them.
CP: Really? That's your argument?  We are the better profession. We are the last line in making sure our patients take their medications correctly. When was the last time you had to do an MTM and the patient remembered every OTC item they were taking? If we fill them as Rxs, we have them on file. We can run drug interactions against the other medications we are filling. Why would we not fill these as prescriptions?
Me: The patients won't pay for them.
CP: The patients who have FSA accounts will be happy to pay for them. Many plans will only allow their funds to go towards Rx items. If they walk up with a box of Pepcid, their card will not allow the purchase. They may be able to submit the receipt, but this is easier for them. Also, they can bypass the Pseudoephedrine limits and get a whole month of Claritin-D or Allegra-D if we fill it as a prescription.
Me: What about supplies?
CP: What about them? We already bill Glucose meters, test strips, lancets, alcohol pads, syringes, and pen needles on prescriptions. How would a nebulizer be any different? We do those too. Once you find an NDC that works, order it. Bill it. Fill it.
Me: Crutches?
CP: I have.
Me: So there are a lot of items we could bill?
CP: Yes. The vast majority of OTC prescriptions we fill are for former or current Rx items (Ibuprofen, APAP, ASA, Pepcid, Zantac, Prilosec, Flonase) and Mucinex, Delsym, Benadryl, eye drops, ear drops, etc. All you have to do is find one once and keep it on the shelf. Our job is to provide healthcare. I fail to see how telling people to buy something OTC when we received it as a prescription is doing our job.

Remember:
Some insurances pay for OTC items. If not, override the price.
The patients will have the correct instructions.
The patient doesn't have to purchase a whole box if they only need a week supply.
FSAs will pay for OTCs as Rx items.
We will have a more complete medication history for interactions.
Patients will be happy.
It's no more work than any Rx item you're already filling.
We get paid to fill prescriptions. (ps these count as prescriptions too.)

As for my note at the top, I knew the patient's insurance would cover the medication with a PA which is why I faxed it initially. We filled it on a discount card for less than OTC and the patient was happy.

Kiwis

I had this already written but hadn't decided when to post it. When I received the e-script, it made the post that much better.

CP: I'm calling to get the patient's e-script changed from Humalog vials to Humalog Kwik Pens.

Nurse: Okay. You want the Kiwi Pens?

CP: No. I want Kwik Pens.

Nurse: The Kiwi Pens?

CP: You do work in an endocrinologist's office, right?

Nurse: Yes.

CP: They're called Kwik Pens. Not Kiwis. Can you just send me a new prescription for the Humalog KWIK Pens so we don't have to go through this every month.

Nurse: I'll ask the doctor about Kiwi Pens.

CP: If he doesn't explain to you they're Kwik Pens, I'll come over and kick him in the kiwis.

Nurse: He said it's okay to give him Kiwi Pens.

CP: Is that the punchline to a really lame joke? 

What do New Zealanders write with? Kiwi Pens?

Nurse: Um. . . No? Anything else? 

CP: Yes We need pen needles so the patient can inject Kiwis. 

Nurse. Okay. I'll send those over shortly. 

CP: I can't wait to see what I get. 

<later> 

CP: Wikipedia? WTAF?

I'm Out

Out: at an end.

1. My pen ran out of ink.
2. My car is out of gas.

While these two sentences may seem similar, they are not. Irrespectively, one is quite dire while the other is often easily remedied. Most people, when confronted with the first, an empty pen, will generally reach for a new pen. They will not attempt to refill the empty cartridge. In the second scenario, most people don't have gas cans on hand to refill their cars; they also will not reach for a new car.

Me: CP, where are you going with this?
CP: Patients. I mean, patience. I'm going to illustrate the perception people share regarding their refills.
Me: Is this another one of your "Refill Too Soon" episodes?
CP: Mayhap.
Me: Phine. Can we just call it #EverydayPeople?
CP: Very Sly. . .

Medication Taker: I wish to phone in my refill.
CP: Brilliant! We do those here. May I have the number in question, please?
MT: 8675309.
<Me: Really? That's the best you could do?>
<CP: Shut it Jenny. Not everyone will catch it.>
CP: Okay. I see we have your refill on file but it appears it's going to be too soon to refill.
MT: But I'm out.
CP: Out?
MT: Yes?
CP: Like Out Out?
MT: Yes.
CP: Well you shouldn't be.
MT: The bottle in my hand is completely empty.
CP: According to my mathletics, you should have enough for at least 3 more weeks.
MT: But I'm all out.
CP: Are you still taking 2 tablets per day?
MT: Yes.
CP: By any chance, are you a squirrel?
MT: Sorry?
CP: Did you happen to stash some nuts around the room for winter?
MT: Well I just filled my pill container for the next month, added some to my extra bottle, the bird feeder, and sprinkled some in the carpet in case I fall down and need to take my medication without standing.
CP: Ok.
MT: But this bottle is empty!
CP: Right. What you're telling me is that you're not really "out of medication" in so much as your one bottle (pen) is empty. Instead of buying another tank of gas for the old pen, reach for another pen. Only when they all run dry should you need to buy more.
MT: That's a confusing metaphor.
Me: You can say that again.
CP: Look. It's quite easy. You're not out if you still have some. Everyone has a stash of pens at home. You have a stash of drugs at home.
Me: That sounds bad.
CP: Shut it. You know what I mean.
Me: Can I throw in another random quote? It is germane to the "stash of drugs reference.
CP: Phine.
Me: "We grow copious amounts of ganja, yah? And you're carrying a wasted girl and a bag of fertilizer. You don't look like your average horti-****ing-culturist!"
CP: Thanks for that. Now just inform everyone that they cannot claim to be out of medication unless they are actually out. 
Me: But don't we want them to refill everything a few days early. 
CP: Yes. A few days is perfect, but 3 weeks is quite excessive. 

Liability, Obligation, or Duty?

Here is a quick lesson/refresher for patients and pharmacists and prescribers who may not know how the system works. 

1. Patient is unwell and goes to their prescriber. 

2. Prescriber makes a diagnosis and prescribes a medication. 

3. Patient goes to pharmacy to have medication filled. 

4. Pharmacy fills medication and charges patient the price. 

a. price could be cash with no insurance being billed. 

b. price could be a copay on their insurance which may or may not include a deductible. 

c. price could be on a discount card patient brought to pharmacy. 

5. Patient pays and leaves with medication. 

This should look similar to every other transaction any person would have at any retail outlet. 

1. You decide to purchase a product. 

2. You research the product you wish to purchase. 

3. You go to the retailer to purchase the product. 

4. Retailer finds your product (or you take it to the register) and they charge you for it. 

a. price could be cash with no discounts. 

b. price could be with an online offer, price match, or in-store sale. 

c. price could be with a coupon. 

5. You pay for your purchase and go home. 

Why is the pharmacy to blame? 

They aren't. The ultimate responsibility rests with the patient. If they want/need the medication I, as the dispenser of the medication, have an obligation to tell them how to receive it and provide it to them. That is all. We bill insurances as a courtesy. If your pharmacy has told you your prescription needs a prior authorization, you need to figure out how to get one. 

Here is how it works: 

1. When filling your prescription, we submit the claim to the insurance we have on file. (note-this may or may not be your most current one. I said it's the one we have on file.)

a. the claim goes through and we get a paid claim with a copay to charge you. 

b. the claim rejects for some reason (max days supply, dosing, refill too soon,) and we fix it and reprocess. 

c. The claim rejects for "prior authorization required". At this time, we fax your prescriber, then we call you so you don't rush down here. (Sometimes I have called patients while they are still in the office.) We then set up the claim to reprocess in 2 days. and repeat all parts of Step 1 a-c.

2. You accept the terms of our billing process and pay, or not. 

3. At any time, YOU can call your insurance to request a prior auth. 

Here is my dialogue to patients on prescriptions requiring PA: 

"Mr. Pink. We received a new prescription from your doctor this morning and your insurance does not cover it. They require a prior authorization as it is not a preferred item. We faxed the office so hopefully they can start the process. We will reprocess this claim every other day for a week but we suggest you follow up with your provider as no one ever calls us to let us know if the p/a was approved or not. It is possible your provider may wish to change medications or, in some cases, ignore the request altogether. You also have the option to pay cash for your medication which is $$$$$. If you have any questions, please call the office first, your insurance second, and me last. Good Day."

Now that we understand how a pharmacy works, let's look at the article: https://www.masslive.com/politics/index.ssf/2018/06/woman_dies_because_of_missing.html

A. "a pharmacist has a duty to tell both the patient and their physician when filling a prescription requires prior authorization." 

Yep. We do that. 

B. "Pharmacists simply must take reasonable steps to notify patients and prescribing physicians that, if the physician wants a patient to receive insurance coverage for the prescribed medication, the physician must complete a form"

Yep. As I said, we do that. Faxed them. Called them. Told the patient to call them. 

C. "it is actually the job of the doctor and insurer to determine coverage."

Yep. Insurance doesn't want to pay. We tell the patient and the doctor. 

D. "But once she turned 19, MassHealth's policy was to require prior authorization. Essentially, her doctor had to send a form to MassHealth requesting coverage for the medication."

Wait. So everyone knew this already? First, why does the insurance require prior auth at 19 yo? Did something change? Does it suddenly work differently in an 18 yo patient than a 19 yo patient? But again, if everyone knew this when she was 18, why was this not taken care of by the insurance and her provider beforehand? Why did the patient not make sure she had enough medication to last through the first few weeks/days of the transition?

E. "Rivera's stepfather said he called Schoeck's office seven times about obtaining prior authorization, but he was relying on Walgreens to send Schoeck the form.

Why? Why is it the pharmacy's responsibility to send the form. Look, I can fax 'em, call 'em, drive over there and throw the requests at 'em in the form of little paper airplanes or table footballs but I simply can NOT make them submit the prior auth. 

F. " Her family was told it would cost $400 to pay out of pocket, which they could not afford."

Why? Unfortunately the article does not explain which Topamax this is although I suspect it is not the tablets. (If it was an extended release product, why did no one suggest a change to tablets? I can buy #120 Topiramate 100mg tablets for ~$25.00. You mean no one else thought to look at this as a stop-gap option?) 

G. "The ruling noted that the pharmacist knows the proper forms and procedures needed for prior authorization, which a patient generally does not."

Nope. I have no clue what the forms are. I do not possess, nor do I know how to obtain them. The reject from the insurance company simply provides me with a phone number for the prescriber to call to get the forms. I know there is a company, Cover My Meds, that takes p/a requests from pharmacies and forwards the correct forms to the providers electronically but that's all I know about it. 

So I ask again, why is the insurance not to blame? 

How To Be A Good Patient

<our scene unfolds in a non-native environment for our hero, CP>
Other Pharmacy Personnel: Hello and welcome to OPP's pharmacy.
CP: Thank you.
OPP: How may we help you today?
CP: <sheepishly> I am here to pick up prescriptions.
OPP: Are these for you?
CP: No. I do not usually shop here. I am picking up for a phriend who is required to use this phine establishment.
OPP: Well thank you for coming to visit today. Do you know how many prescriptions you are retrieving?
CP: Alas, I do not. I was forwarded the text alerting my phriend that there were prescriptions ready. How many do you have?
OPP: I have three prescriptions ready.
CP: May I inquire as to what they are?
OPP: Yes. We have the puce one, the periwinkle one, and the pretty fuchsia one.
CP: Can you remove the puce one, please? I believe I requested that to be discontinued last visit.
OPP: You are quite correct and I apologise for the mistake. I do remember speaking with you last month and personally removing this from our list. Unfortunately computers, despite our bet intentions, suck.
CP: Indeed they do.
OPP: I shall remove it forthwith.
CP: Many thanks. This is why I always check what I am receiving before I leave.
OPP: As all good patients, and <wink, wink> professionals, should.
CP: It truly is amazing how rewarding an experience one can have when one takes control of their own healthcare and works with their pharmacy instead of against them.
OPP: Indeed. Good day!
CP: Good day!

This has been a presentation of #HowToBeAGoodPatient and #HowToBehaveInPublic as brought to you by CP and Other People's Pharmacy.

Too Many Choices/Too Much Help

"In this day and age, a man has to have choices, a man has to have a little bit of variety."
On the one hand, this is true. On the other, too many choices can cripple a man. If you want to prove this, take a group of first grade children for ice cream. If you give them the options of either chocolate or vanilla, you will be happy and be able to exit the parlour relatively quickly and with most of your sanity intact.
Take the same group to Baskin Robbins and time and sanity will be forever lost. Too many choices cripples the group.

The same can be said for healthcare.
"The more care we provide for patients, the less they are able to do for themselves."
We text patients it's time to refill their prescriptions.
We text patients it's time to pick up the refills we filled for them.
We text patients it's still time to pick up their refills.
We call patients to make sure they received our texts.
We call and fax the patients' prescribers for their refills.
We look up their new insurance information.
We check their copays.
We call for prior authorizations.

When the system breaks down, the patients are crippled because they don't know how to properly call in a refill request to the pharmacy or prescriber.
They don't know how to make their own appointments.
They don't understand their insurances anymore.
They don't understand how to do anything for themselves.
Their personal care becomes dependent upon our broken system.
In an effort to help them, we are actually hurting them.

Think of the millennial bashing. It's a great pastime but it's not entirely their fault.
It's their parents' fault.
They established a sense of entitlement.
Mommy and daddy will call your teacher because you got a bad grade.
Mommy and daddy will move to whatever town you decide to go to college.
Mommy and daddy will write your resume and go to your job interview with you.
Now we have a bunch of "not-yet-ready-for-primetime players".

Too much care equals too little personal agency.
The initial intent of predictive refill programs and reminder calls was noble: increase compliance to increase patient outcomes. I know there are studies to support the positive outcomes. The problem is our profession ran with these programs and made them into metrics. Once that happened, the nobility wore off while Jekyll and Hyde switched places.

The less we do, the more helpful we will be.
It seems to work from a corporate standpoint: They cut our help expecting us to do more.
Let's apply that to patient care.
Let's do less for them so we can do more.

"Give a man a fish and he eats for a day. Teach a man to fish and he eats for a lifetime."