Because of my recent....transition.... in employment status, I have a new job.
I love it.
I am working at an independent compounding pharmacy. It's a perfect mix for me: challenging but laid back. My boss crusies on match.com for a while, then makes a geometric dilution for a triiodothyronine aliquot.
Today, the tech made Mustargen ointment.
Seriously.
(I am still afraid of touching chemo agents, but maybe I'm a chicken.)
We do a lot of bioidentical hormone replacement therapy: estriol, estradiol, DHEA, testosterone, progesterone, pregnenolone.... in every combination and in every dosage form imaginable. Tablet triturates, troches, mini troches, creams, gels, ointments, suppositories, capsules.
I made a nasal spray today in which I put budesonide in a bottle of Astelin. Some drug company needs to market THAT.
My favorite things about my new job are the people and the hours. I work with PEOPLE; another pharmacist and 3 techs. After working such long hours at my last job alone most of the time, it's fun to get to have relationships with coworkers again. And I no longer have to work nights, weekends, holidays.
I get to eat lunch. It's like a pharmacy dream.
Tuesday, April 29, 2008
Flat Co-pays and the Public's Inability to Understand Them
(This is the last of my old posts, republished. Anything published from here on out will be new material. Enjoy!)
A man comes to pick up a prescription today. It was a refill that we had faxed his doctor on, for Avodart. The doctor only approved #15 capsules because the patient had not had an appointment in over a year. His insurance company charges a flat $60 copay for this non-formulary medication for a montly supply, and #15 capsules cost $56.99 because they just charged him the cash-Rx price instead of the $60 copay.
He yelled at me, saying that me and my company were screwing him. He hardly let me get a word in edgewise. He kept asking “What about the other 15 capules?” He claimed that my company was overcharging him and no other pharmacies did this and he was calling the Better Business Bureau and whatnot.
I had to tell him that there were no other 15 capsules, his doctor had only authorized 15 and that is all I could fill. I didn’t set his copays, I billed claims to his insurance and they tell me what to charge. He thought that 1/2 prescription should have 1/2 copay (or $30) no matter how many times I told him it didn’t work like that. I told him he was welcome to call his insurance company and ask them about it.
After he left, I sat here fuming, wishing I would have said this:
“Listen up, if anyone is at fault for this high copay on only 15 capsules it is not the pharmacy. Let me tell you the three entities you should be blaming.
Number one: YOURSELF. Last month your doctor’s office told you that you need an appointment, that it had been more than a year. You ignored them. Now, when they only authorize 15, you have only yourself to blame. If you had made an appointment, they would have authorized a month or more.
Number two: your doctor’s office. Most doctor’s offices know that there are flat copays on brand name drugs, and that you will have to pay the same copay no matter how many you get. Even if you haven’t had an appointment in more than a year, they should still authorize 30. Unless it’s a controlled substance.
Number three: your insurance company. They are the ones that you should call and bitch about copays to, because I have absolutely NO CONTROL over them. You might as well bitch at yourself because you’re the one that picked the plan. Oh, and your doctor, too, because he’s the one that prescribed that non-formulary medication for you.
I, on the other hand, was nice enough to fax your doctor three times for the refill on this prescription. As you can now see, me and my pharmacy had nothing to do with this situation, and if you still can’t understand why there is nothing more I can do for you.”
Thanks, I feel better now.
A man comes to pick up a prescription today. It was a refill that we had faxed his doctor on, for Avodart. The doctor only approved #15 capsules because the patient had not had an appointment in over a year. His insurance company charges a flat $60 copay for this non-formulary medication for a montly supply, and #15 capsules cost $56.99 because they just charged him the cash-Rx price instead of the $60 copay.
He yelled at me, saying that me and my company were screwing him. He hardly let me get a word in edgewise. He kept asking “What about the other 15 capules?” He claimed that my company was overcharging him and no other pharmacies did this and he was calling the Better Business Bureau and whatnot.
I had to tell him that there were no other 15 capsules, his doctor had only authorized 15 and that is all I could fill. I didn’t set his copays, I billed claims to his insurance and they tell me what to charge. He thought that 1/2 prescription should have 1/2 copay (or $30) no matter how many times I told him it didn’t work like that. I told him he was welcome to call his insurance company and ask them about it.
After he left, I sat here fuming, wishing I would have said this:
“Listen up, if anyone is at fault for this high copay on only 15 capsules it is not the pharmacy. Let me tell you the three entities you should be blaming.
Number one: YOURSELF. Last month your doctor’s office told you that you need an appointment, that it had been more than a year. You ignored them. Now, when they only authorize 15, you have only yourself to blame. If you had made an appointment, they would have authorized a month or more.
Number two: your doctor’s office. Most doctor’s offices know that there are flat copays on brand name drugs, and that you will have to pay the same copay no matter how many you get. Even if you haven’t had an appointment in more than a year, they should still authorize 30. Unless it’s a controlled substance.
Number three: your insurance company. They are the ones that you should call and bitch about copays to, because I have absolutely NO CONTROL over them. You might as well bitch at yourself because you’re the one that picked the plan. Oh, and your doctor, too, because he’s the one that prescribed that non-formulary medication for you.
I, on the other hand, was nice enough to fax your doctor three times for the refill on this prescription. As you can now see, me and my pharmacy had nothing to do with this situation, and if you still can’t understand why there is nothing more I can do for you.”
Thanks, I feel better now.
Don't Lie to Your Pharmacist, Part II
A woman just called me and asked me to transfer a prescripton for Ultram from Wal Mart. She said the pharmacist there wouldn’t fill it, because it’s early. The doctor had called to authorize an early refill, but the pharmacist on duty still would not fill it three weeks early (go unknown Wal Mart pharmacist!)
She said she was going to a funeral in Montana and the nearest pharmacy was “80 miles” from where she was staying or she would transfer the prescription to another pharmacy to fill when it was due.
I told her that I would have to ask about her history at the other pharmacy before I would transfer it (I knew that I wouldn’t either way) and inquired as to where she was traveling in Montana, as I’m from that part of the country.
She said the funeral would be in Missoula.
I told that I had been to Missoula on several occasions and there were most definitely pharmacies within city limits, and when I did a Google search with “pharmacy” and “Missoula” as subjects, I got no less than 9 local business results, including a Wal Mart Pharmacy. In fact, I think that there are probably no places in the lower 48 states that are 80 miles from a pharmacy.
When I told her that, she hung up on me. I hope the next pharmacist she calls knows Montana’s geography, too.
Or has a highly attuned bullshit sensor
She said she was going to a funeral in Montana and the nearest pharmacy was “80 miles” from where she was staying or she would transfer the prescription to another pharmacy to fill when it was due.
I told her that I would have to ask about her history at the other pharmacy before I would transfer it (I knew that I wouldn’t either way) and inquired as to where she was traveling in Montana, as I’m from that part of the country.
She said the funeral would be in Missoula.
I told that I had been to Missoula on several occasions and there were most definitely pharmacies within city limits, and when I did a Google search with “pharmacy” and “Missoula” as subjects, I got no less than 9 local business results, including a Wal Mart Pharmacy. In fact, I think that there are probably no places in the lower 48 states that are 80 miles from a pharmacy.
When I told her that, she hung up on me. I hope the next pharmacist she calls knows Montana’s geography, too.
Or has a highly attuned bullshit sensor
At Least Barristas Get Tips
This morning I was getting my daily dose of caffeine at Starbucks. I was in line behind 3 or 4 people, but the line was moving along. The barristas were friendly, chatting with customers as they steamed milk for lattes and blended ice and sugar-water for frappuccinos. A woman rushed in, interrupted the transaction of the person that was paying at the register and demanded to know how long the wait was.
The barrista replied smartly, “It depends on what the people in front of you order.” It totally killed the friendly mood of the Starbucks staff, they kept glaring at the impatient woman tapping her foot and checking her watch.
I had deja vu later today when another woman (why is it always women? I hate to be a traitor to my kind, but jeez) interrupted me with exactly the same question regarding prescription wait times.
This takes me back to that stupid USA Today article that I can’t quit thinking about. People want it (whatever IT is) FAST, not right. I’m sure they could have sold the in-a-hurry woman a cup of expired milk or dishwater and it would be fast, but it wouldn’t be the grande-triple-shot-skinny-soy-sugar-free-vanilla/hazelnut-extra-hot-no-foam-latte that she wants. People need to understand that they can have things FAST or RIGHT.
As with their Starbucks order or their prescription, accuracy takes patience. Slow down, people.
The USA Today article points out that high prescription volume increases chance for errors. I have worked in a high-volume store. There is a big difference between filling a lot of prescriptions for people coming in tomorrow (no huge rush) versus having 20 people in the waiting room glaring at you because their prescription isn’t being filled fast enough.
I guess the moral of my story is to call in your prescription a day or two before you need it, and to be patient with the barristas at Starbucks. They might just spit in your cup, otherwise.
The barrista replied smartly, “It depends on what the people in front of you order.” It totally killed the friendly mood of the Starbucks staff, they kept glaring at the impatient woman tapping her foot and checking her watch.
I had deja vu later today when another woman (why is it always women? I hate to be a traitor to my kind, but jeez) interrupted me with exactly the same question regarding prescription wait times.
This takes me back to that stupid USA Today article that I can’t quit thinking about. People want it (whatever IT is) FAST, not right. I’m sure they could have sold the in-a-hurry woman a cup of expired milk or dishwater and it would be fast, but it wouldn’t be the grande-triple-shot-skinny-soy-sugar-free-vanilla/hazelnut-extra-hot-no-foam-latte that she wants. People need to understand that they can have things FAST or RIGHT.
As with their Starbucks order or their prescription, accuracy takes patience. Slow down, people.
The USA Today article points out that high prescription volume increases chance for errors. I have worked in a high-volume store. There is a big difference between filling a lot of prescriptions for people coming in tomorrow (no huge rush) versus having 20 people in the waiting room glaring at you because their prescription isn’t being filled fast enough.
I guess the moral of my story is to call in your prescription a day or two before you need it, and to be patient with the barristas at Starbucks. They might just spit in your cup, otherwise.
I Wish I Was a Drug Rep for Azithromycin
Filled 83 prescriptions the other day. 9 of them were for Zithromax (either a Zpak or Zithromax oral suspension). That means 10.3% of my presription volume was an azalide antibiotic.
What about doxycyline, amoxicillin, sulfamethoxazole/trimethoprim? What about fluoroquinolones (except ciprofloxacin, which has little activity against Streptococcus pneumoniae)?
What about delaying or avoiding antimicrobial therapy, as most cases of respiratory infections are viral in nature?
CDC guidelines for adults suggest that only 10% of pharyngitis cases are caused by group A beta hemolytic strep. If the infection is determined to be caused by strep, treatment of choice is PENICILLIN (or erythromycin for penicillin allergic patients).
Rhinosinusitis infections are caused primarily by viruses. If symptoms last longer than 7 days, infection with the bacteria Streptococcus pneumoniae or Haemophilis influenzae may be considered, and should treated with antibiotics that cover both bacteria (amoxicillin, Augmentin, Ceftin, or Bactrim would work, as well as Zithromax and Levaquin).
Bronchitis can be treated with a Zpak, but prescribers can also use Bactrim, doxycycline, Augmentin, Ceftin, Cipro, or Levaquin.
Overuse of a single antibiotic increases bacterial resistance to that product. Maybe spread the love around a little, guys.
What about doxycyline, amoxicillin, sulfamethoxazole/trimethoprim? What about fluoroquinolones (except ciprofloxacin, which has little activity against Streptococcus pneumoniae)?
What about delaying or avoiding antimicrobial therapy, as most cases of respiratory infections are viral in nature?
CDC guidelines for adults suggest that only 10% of pharyngitis cases are caused by group A beta hemolytic strep. If the infection is determined to be caused by strep, treatment of choice is PENICILLIN (or erythromycin for penicillin allergic patients).
Rhinosinusitis infections are caused primarily by viruses. If symptoms last longer than 7 days, infection with the bacteria Streptococcus pneumoniae or Haemophilis influenzae may be considered, and should treated with antibiotics that cover both bacteria (amoxicillin, Augmentin, Ceftin, or Bactrim would work, as well as Zithromax and Levaquin).
Bronchitis can be treated with a Zpak, but prescribers can also use Bactrim, doxycycline, Augmentin, Ceftin, Cipro, or Levaquin.
Overuse of a single antibiotic increases bacterial resistance to that product. Maybe spread the love around a little, guys.
Pharmacy and My Ayn Rand Obsession
What is your favorite smelling drug?
Most pharmacists agree that products manufactured by Abbott smell appetizingly like vanilla. Almost wants me want to take Depakote. Benicar smells like butterscotch.
Chewable carbamazepine 100mg tablets smell good. Well, I guess most chewable tablets smell yummy. Brand-name Amoxil suspension’s smell brings me back to when I was a kid and bubblegum was my favorite flavor. It still smells good.
Least favorite smelling drugs are easier. My least favorite is spironolactone. The brand name
Aldactone tablets were perfumed to smell minty-fresh. The generic sort of smells like dog farts. It is disgusting.
Brand-name Glucophage smells like rotting fish, and surprisingly the generic metformin doesn’t. I will not count Armour Thyroid tablets (made of crushed up animal thyroid glands) until I absolutely have to because smelling them makes me throw up in my mouth a little. I have to hold my nose. Everyone knows that cephalexin smells like gas. That’s flatulence gas, not gasoline.
My absolute favorite smelling drug is Midrin capsules. Brand, generic: it doesn’t matter. Those things smell GOOD. Not in a food-good way, either. Kind of like architect’s erasers. Every time I have to fill a prescription for them I have one of those funny dream sequences where I imagine myself in a compromising position on the drafting desk of Howard Roark.
So, pharmacists and technicians, tell me. What’s YOUR favorite smelling drug?
Most pharmacists agree that products manufactured by Abbott smell appetizingly like vanilla. Almost wants me want to take Depakote. Benicar smells like butterscotch.
Chewable carbamazepine 100mg tablets smell good. Well, I guess most chewable tablets smell yummy. Brand-name Amoxil suspension’s smell brings me back to when I was a kid and bubblegum was my favorite flavor. It still smells good.
Least favorite smelling drugs are easier. My least favorite is spironolactone. The brand name
Aldactone tablets were perfumed to smell minty-fresh. The generic sort of smells like dog farts. It is disgusting.
Brand-name Glucophage smells like rotting fish, and surprisingly the generic metformin doesn’t. I will not count Armour Thyroid tablets (made of crushed up animal thyroid glands) until I absolutely have to because smelling them makes me throw up in my mouth a little. I have to hold my nose. Everyone knows that cephalexin smells like gas. That’s flatulence gas, not gasoline.
My absolute favorite smelling drug is Midrin capsules. Brand, generic: it doesn’t matter. Those things smell GOOD. Not in a food-good way, either. Kind of like architect’s erasers. Every time I have to fill a prescription for them I have one of those funny dream sequences where I imagine myself in a compromising position on the drafting desk of Howard Roark.
So, pharmacists and technicians, tell me. What’s YOUR favorite smelling drug?
Finally, Getting Some Publicity
An article printed in today’s issue of USA Today will hopefully help to improve pharmacists’ working conditions. It is called “Rx for Errors: Speed, High Volume Can Trigger Mistakes.” It details several prescription errors made by Walgreens and CVS pharmacists that may or may not be a direct result of large prescription volume.
The chains, of course, are denying that volume plays a role in whether or not mistakes are made. Internal documents showed that Walgreens expects pharmacists to fill and check prescriptions in two minutes, hardly leaving enough time to do a prospective DUR or counsel a patient. CVS times pharmacists on how fast they fill prescriptions and answer the phone. Sound stressful? It does to me. Do you think that stress and high volume would increase potential for human errors? The chains may try to deny it, but any sane person would agree that such an environment would only foster mistakes.
I have been a staff pharmacist in a store that filled 2000 prescriptions a week with 2 and 1/2 pharmacists. It was not unusual for us to fill over 400 prescriptions on a Monday. Sometimes I felt like my head would explode, and a lot of the responsibilities that I felt were mandatory for pharmacists (like counseling) were ignored. There just wasn’t time. When the chain I worked for was bought by CVS, I knew it would only get worse. It was only a matter of time before I made a serious error on a prescription because I didn’t have time to properly check it or didn’t talk to the patient (proper counseling is the BEST way to prevent errors). I was kept up at night, unable to sleep, dreaming about prescriptions I filled and having nightmares about prescription errors I could have made.
I was good at my job in the busy pharmacy. My techs were glad that it was me opening with them in the morning, because I was fast and accurate. We would fill 200 prescriptions from 9-1, when the other pharmacist arrived. I was praised by upper management. I would brag about how many prescriptions I filled and how short of time it took me to do it. But I knew that my patients were suffering because I didn’t have time to talk to them about their prescriptions. I knew that the company was squeezing every last drop out of me. I was being taken advantage of, and I was bragging about it! It had to stop. I quit before the CVS merger, and transferred to a job as a pharmacy manager in a grocery store chain.
Now, I work in a slow store, we fill roughly 500 prescriptions a week. Much of the time I am bored. But, thankfully, I have adequate time to fill each prescription that comes through my door. I counsel my patients, fax doctors detailed reports regarding drug interactions or side effects, and verify every prescription thoroughly. I have never made a mistake that I know of (Knock on wood). Yet. I know that I will eventually (I am human), but I am confident that, in my current job, I have enough time to do my job properly.
I work 12 hour days without breaks. So do many pharmacists that work for Walgreens or CVS (those guys work 14s). If I was in a more stressful environment, mistakes would be much more likely. It’s common sense. Your brain never has a chance to decompress.
Pharmacists for these chains need to refuse to fill prescriptions at such a rate. It is the individual pharmacist’s license on the line. If they feel they can’t do their job safely, they need to stand up and say it. It’s NOT WORTH IT to be the good-little-boy or girl pharmacist filling 2 prescriptions a minute and make a mistake that could cost someone their life.
The chains, of course, are denying that volume plays a role in whether or not mistakes are made. Internal documents showed that Walgreens expects pharmacists to fill and check prescriptions in two minutes, hardly leaving enough time to do a prospective DUR or counsel a patient. CVS times pharmacists on how fast they fill prescriptions and answer the phone. Sound stressful? It does to me. Do you think that stress and high volume would increase potential for human errors? The chains may try to deny it, but any sane person would agree that such an environment would only foster mistakes.
I have been a staff pharmacist in a store that filled 2000 prescriptions a week with 2 and 1/2 pharmacists. It was not unusual for us to fill over 400 prescriptions on a Monday. Sometimes I felt like my head would explode, and a lot of the responsibilities that I felt were mandatory for pharmacists (like counseling) were ignored. There just wasn’t time. When the chain I worked for was bought by CVS, I knew it would only get worse. It was only a matter of time before I made a serious error on a prescription because I didn’t have time to properly check it or didn’t talk to the patient (proper counseling is the BEST way to prevent errors). I was kept up at night, unable to sleep, dreaming about prescriptions I filled and having nightmares about prescription errors I could have made.
I was good at my job in the busy pharmacy. My techs were glad that it was me opening with them in the morning, because I was fast and accurate. We would fill 200 prescriptions from 9-1, when the other pharmacist arrived. I was praised by upper management. I would brag about how many prescriptions I filled and how short of time it took me to do it. But I knew that my patients were suffering because I didn’t have time to talk to them about their prescriptions. I knew that the company was squeezing every last drop out of me. I was being taken advantage of, and I was bragging about it! It had to stop. I quit before the CVS merger, and transferred to a job as a pharmacy manager in a grocery store chain.
Now, I work in a slow store, we fill roughly 500 prescriptions a week. Much of the time I am bored. But, thankfully, I have adequate time to fill each prescription that comes through my door. I counsel my patients, fax doctors detailed reports regarding drug interactions or side effects, and verify every prescription thoroughly. I have never made a mistake that I know of (Knock on wood). Yet. I know that I will eventually (I am human), but I am confident that, in my current job, I have enough time to do my job properly.
I work 12 hour days without breaks. So do many pharmacists that work for Walgreens or CVS (those guys work 14s). If I was in a more stressful environment, mistakes would be much more likely. It’s common sense. Your brain never has a chance to decompress.
Pharmacists for these chains need to refuse to fill prescriptions at such a rate. It is the individual pharmacist’s license on the line. If they feel they can’t do their job safely, they need to stand up and say it. It’s NOT WORTH IT to be the good-little-boy or girl pharmacist filling 2 prescriptions a minute and make a mistake that could cost someone their life.
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