Not the job for me

Sometimes you know when a situation is not a good fit. The recruiter may present a position that appears to be "the" perfect situation. Rather than jumping in feet-first, sometimes it is better to carefully stick your toe in, pull it back out, repeat several times before committing.

Let me share.

A couple years ago my employer had made some moves that I deemed to be less than good for the pharmacy division of the company. Little things like cutting technician hours, not giving pharmacists raises for over 18 months. Things like that.

So when the recruiter called with a 9-5:30 Monday thru Friday position, I was interested. It was in a town where I had worked previously so I knew the physician and patient populations. The store wasn't very busy (the recruiter's words were "tremendous potential for growth") so I wasn't getting thrown into the lion's den.

Benefits were paid entirely by the company. Three or four weeks of vacation from day one. Salary was the highest in the local market (and a thirteen percent increase over my current wages). I would be going in as the pharmacy manager, so it would be a lateral move for me. Tech coverage every hour that we were open, plus a couple cashiers/stockers at all times.

I drove down for the interview. The company had two operations. A home infusion side that employed several nurses and pharmacists and serviced a large geographic area. The tour of that side was interesting. I found it amazing that such a seemingly small company was able to employ so many people who earned nurse and pharmacist wages.

The retail pharmacy side (for which I was applying) was the family business. Had been for a few decades. It wasn't what it once was, but the owner wanted to keep it going in honor of her late father who was the pharmacist. With the right people, I could see it making a comeback.

The actual pharmacy layout was that of an old-time soda fountain. Rumor was that the pharmacy had the best milkshakes in town. Now I happen to love milkshakes, so this was looking like a real good fit.

At the back of the storefront was the actual pharmacy lab. It was considerably dated, but it was workable. As business grew, I could see a remodel as a possibility.

The pharmacy didn't seem too hectic. I spoke with the pharmacist who was working that day and he didn't seem too stressed. He was one of the pharmacists from the home infusion side who came over to do retail one day per week. Actually all of the home infusion pharmacists worked a day of each week on the retail side until a permanent pharmacist could be found.

As for the actual interview, it was in the owner's office with both the owner and the business manager. The office was not the most organized, but who am I to judge. Whenever I'm reorganizing my area can look pretty much the same as that office. When I left, we had the understanding that we would be in contact later that week.

By the time I drove back home (40 minutes), there was a job offer in my inbox. A little soon, I thought. A company that jumps that quickly might be a little too desperate. I called them the next day to talk a little more. We decided that I would come down to work a few shifts and see if I liked the environment and to see if I meshed with the staff on the retail side.

The first day I worked was a Monday. And for a Monday it wasn't bad, at least volume-wise.

The computer system was from the early 90s. I mean no updates or anything. The tech said that the owner bought it from a sorority sister. That's all I need to say about that. After messing around for the first hour or two, I figured out how to operate the system and things were running fairly well.

Now about the tech help. That would have been nice. The "tech" was able to remove bottles from the shelves, dust, and place the bottles back on the shelf. That is what her assignments were for the day. Not to assist the pharmacist. Not to answer the phones. Computer? She didn't even know how to log-on. Not exactly the picture I had in my head based on the recruiter's call and the interview.

The day went slow. I think I filled about sixty scripts, but since I was learning a new system I didn't have much down-time. It just went slow.

At the end of the day, I wanted to place the drug order. That's when I found out that they didn't order every day. I guess I can understand that since they were low-volume. Then I saw who their wholesaler was. Every pharmacy in town was serviced by local wholesalers. This place used a small wholesaler based several hundred miles away. That was a red flag. Then I saw the owe stack. There were owes from three weeks prior. Apparently they hadn't placed a drug order for three weeks.

The business manager, a non-pharmacist, came down near the end of the day. I handed him a list of what I thought needed to be ordered. He sat down at his laptop at the fountain and appeared to key in the order. Odd that a non-pharmacist was doing the order, but I thought it was being placed.

When I came back a few days later, the same stack of owes was there. The order hadn't been placed. The business manager pretended to place the order to humor me. After that second day, I knew that this was not a good fit for me. Any place that doesn't care to order medications really isn't exactly a good fit for this pharmacist. At the end of the day, I let them know that I would not be taking the full-time position. They could keep me on their fill-in list, but I wasn't going to be there permanently. Well it took a few pay cycles and a few threats, but I finally received my paycheck for the couple days that I worked there.

After parting with that pharmacy, I spoke to some of the pharmacists who worked in the town. Apparently this pharmacy was known for not paying its bills (thus the far-away wholesaler). A few years earlier the pharmacy had a major infraction with the state board of pharmacy.

Then came the kicker. About a year ago, a news story broke that the home infusion side had been overbilling insurance companies. Something to the tune of a couple million bucks to one insurer alone. The company was in trouble. The home infusion side closed up.

But the retail side remained open. That is until this past Thursday. The owner (a pharmacist), her husband, and two employees were arrested by federal agents for a variety of charges. Makes me glad I gave that place a trial run before committing to working there.

Don't know what to title this post

For those of you out there who may be considering complaining about your insurance at my pharmacy, please consider the following:

• We do not know what insurance plan YOU have, YOU will need to show us a card so we can bill YOUR insurance for YOU.
• We are not the people responsible for the accuracy of the information at YOUR insurance company. YOUR insurance company is responsible for that, as are YOU.
• We can't contact the insurance company to change your information. It's YOUR insurance who has YOUR information wrong. YOU need to correct it or have YOUR benefits coordinator fix it. We will even hand the phone to YOU so YOU can make the call.
• YOUR plan administrator is the one who made the decision to change YOUR plan, not us. YOU were notified by letter back in late November about the changes. Maybe YOU should read YOUR mail so YOU know how YOUR insurance is going to change with the new benefits year.
• I don't know what YOUR copay is going to be until I submit the claim. There's a number on the back of YOUR card called a customer service number. Call it to find out if YOUR medication is covered, and what YOUR copay is going to be ahead of time if you are soooo pressed for time.

And those are just a few of the conversations from the last three hours of work last night.

iHeart MedGuides

On each and every day, thousands of people visit their physicians to discuss their aches and ailments. More often than not, these people leave the office with a prescription in hand or on its way to the pharmacy via e-script, phone, or fax. When this happens, it generates business for retail pharmacists. If your pharmacy is anything like mine, a good portion of these prescriptions are for antidepressants and NSAIDs. You already know what comes next.

The MedGuide.

You know, those handy tear-off sheets that give the patients extra information about their medications. The information that is above and beyond what is included in the drug information that is printed for each prescription.

In theory, the MedGuides are good. They warn the patients about some of the more dangerous things that may happen while taking a particular medication. But the MedGuides aren’t provided to the patients before they receive the medication… they are stuffed into the bag for the patient to review once they get home. After they have dropped sixty bucks for their Celebrex copay or a couple hundred bucks for their Humira. Then the retail pharmacist gets the call about how dangerous the medication is (even though they were counseled) and the patient wants to return it.

It seems to this pharmacist that the physician should be the health care provider who should be responsible for distributing the MedGuides. After all, aren’t they the ones who are choosing to put the patients on these dangerous medications? Don’t they discuss the risks and benefits of therapy with the patient prior to selecting which medication to use? If the patient isn’t sure, shouldn’t they discuss it in the office with the physician prior to bringing the prescription to us?

If a MedGuide isn’t distributed, it’s the pharmacist who takes the blame. In my state, failure to distribute the MedGuide can land you a misbranding citation. In our digital world, you would think that the MedGuides would print automatically with every order that requires one. But they don’t. I’ve only worked with one system that automatically prints the MedGuides and I was shocked when it did. You would think that the software vendors would be required to supply the MedGuides for the medications.

At least the NSAIDs and antidepressants have the generic tear-off MedGuides by the bulk. I checked the warfarin that sits on my pharmacy shelf. The labeling had exactly one MedGuide included. So I then checked my propoxyphene-apap 500-count bottle… one MedGuide. So for these drugs, I get to run to the FDA website to print off a 5 to 8 page MedGuide because the manufacturers aren’t required to provided a sufficient number of these for each bottle of their product.

Physicians aren’t required to provide them prior to ordering medications. Software vendors aren’t required to include them with the patient information sheets. Manufacturers aren’t required to provide adequate quantities of them. Pharmacists must distribute them or face potential fines if they aren’t distributed. It seems to me that pharmacists are getting the short end of the stick when it comes to the MedGuides.

HR 3590 and MTM follow-up

Just a little follow-up on my post about the APhA's claim of victory for having MTMs included in HR 3590. With the results of the election to fill the US Senate seat in Massachusetts, the bill may be dead in the water. But I wanted to shed a little more light on what is going on.

A couple days after the post I received an email from an individual at the APhA to discuss exactly what was going on. After a couple days, I was able to have a conversation with this individual at the APhA to discuss some issues.

I guess that my perspective of the inclusion of MTM in the health care bill was a little jaded. My only experience with MTM has been with Medicare Part D, so that is what I thought the health care bill included. You and I both know that the Medicare D carriers are doing very little to allow retail pharmacists to be able to provide this service. As I said in my previous post, two or three cases over three years isn't anything to get excited about.

In my discussion with the individual at the APhA, I learned that the provision for MTMs in the bill was to include all patients. It's not just Medicare D. This is a good thing.

We've all pissed and moaned that we give away our professional knowledge for free. We're the only profession that does so. Well, this is our opportunity to start billing for our professional knowledge. We whine about MAC + 1.75, $4 generics, and free antibiotics. This may be our chance to get the recognition as health care providers (not just pill dispensers) that we deserve.

The corporate owners of pharmacy are only concerned about the P&L, not the professional side of pharmacy. So it's up to us, as individual pharmacists, to step up to the plate if we want this recognition.

With the health care bill in question right now, you need to stay in contact with the movers and shakers in Washington DC. That means calling your Senator, Congressman, and the APhA. If you don't use your voice, you will lose your voice on this and all matters related to pharmacy as it moves forward.

For me personally, I'm planning on heading out to Washington DC in March to meet some of the APhA people and hopefully have some input on matters related to the profession. I've also contacted about fifteen Medicare D plans to enroll myself as an independent provider of MTM services. MTM is a professional service provided by a pharmacist, not the pharmacy. I don't see letting the corporation keep the reimbursement for my professional services. To take things a step further, I've started applying to different medical plans to be included in their networks as an MTM provider. My thinking is this, nobody will pay us for our services if they don't know that we are out here providing them.

Feel free to shoot me an email at ericrph@msn.com if you have any thoughts on this subject.

Personal responsibility

Personal responsibility. Two words that are heard on a regular basis inside the confines of my pharmacy but don't seem to translate to the masses standing on the opposite side of the pharmacy counter.

Inside the pharmacy, personal responsibility means that you:

• understand how your insurance works, including deductibles, copays, plan limits
• contact your physician when the bottle says "No Refills"
• call ahead to see if your physician phoned in a prescription
• take a proactive role with regards to your prescription medications

But to the people on the other side of the counter, personal responsibility means that:

• the pharmacy staff should know that I am out of refills and call my physician for me
• the pharmacy staff should know the ins and outs of my insurance plan, along with the 700 other plans that they deal with
• the pharmacy staff should call me when my physician calls a prescription in for me
• the pharmacy staff should call me when my physician hasn't called my prescription in yet
• the pharmacy staff should have every medication in stock, including the Mevacor 40mg DAW written by my physician who is 225 miles away
• the pharmacy staff should be able to fill my Vicodin script on Saturday night, ten minutes before closing, even though it was written on Tuesday by the pain management specialist who is only in town once a week, and the prescriber forgot to sign the script
• the pharmacy staff should have the prior authorization done for me, even though I just dropped the order off twenty minutes ago
• the pharmacy staff should have my insurance on file, even if this is my first time at the pharmacy
• the pharmacy staff should have my new insurance on file. They sent the cards out this week

We've all heard these lines a thousand times in just the past week. We like to complain about it, but we're the ones to blame. Well maybe not those of us on the front lines of retail, but the higher ups in the corporate world have created this in the name of "customer service".

Think of the things that we do in the name of customer service that has created this expectation of the customer:

• faxing/ calling for refills
• faxing/ calling for prior auths
• reminder calls to pick up prescriptions
• predictive refills and the courtesy phone calls to let people know their meds are ready
• the list could go on and on and on

We've even allowed the profession to devolve to the point that we are open at all hours of the day, every day of the year.

What other professions carry the hours that pharmacists do?

Physicians?

Lawyers?

Accountants?

Engineers?

Bankers?

For all of these professions, their clients make the time to get to the professional during the professionals office hours. Apparently it's worth the effort to make it to these professionals during their established hours.

Why not us?

Ponder that for a while. I'll follow up in a few days with my thoughts.

Umm...Dr God, there's a little issue with Mary's prescription

I'm starting to get a little fed up with some of my local prescribers. Not because of how they are prescribing. Not because of what they are prescribing. It's what they are prescribing on.

You see, I work in an area of my state that has been hit significantly by the current economic downturn and a considerable portion of my patient population has Medicaid. Even before the economy started to tank there was quite a large portion of my patients who were on Medicaid.

So you would think that the local prescribers would maybe know the rules for prescriptions found in section 7002(b) if the U.S. Troop Readiness, Veterans' Care, Katrina Recovery, and Iraq Accountability Appropriations Act of 2007. To you and me this is the tamper-resistant prescription rule.

And still, on a daily basis, I have to call at least once a day to the same handful of prescribers to notify them that the prescriptions that were just brought to me did not meet the standards of:

• one or more features to prevent the unauthorized copying of the prescription
• one of more features to prevent erasing and modification of the prescription
• one of more features to prevent the use of counterfeit prescription forms

Are they really that dense? Or are the members of the office staff afraid to tell Dr God that he/she needs to order new script pads? I suppose that I can cut some slack to the one physician because spent significant time in Iraq working at a military hospital and he usually e-scribes. He tends to miss the patients whose services are paid for my a Medicaid HMO.

But there is no excuse for Dr God, DDS who just plain out refuses to order the right type of prescription pads. Since my state doesn't require reporting of prescribers who fail to use the tamper-resistant prescription pads, Dr God, DDS can continue to think that he is above the law.

If there is an audit by Medicaid and the prescriptions are deemed to not be written on the tamper-resistant paper, it's the pharmacist/pharmacy who pays. Seems fair, doesn't it? Especially when it's 20 minutes before closing and the patient needs their penicillin and ibuprofen. But they don't have their insurance card so they want it billed as cash. Three days later they come back with their insurance card for a re-bill and it's a Medicaid HMO card. Oh yeah, Dr God DDS didn't use the right kind of paper.

Do you re-bill it and hope to not get audited?

* * * * *

To this pharmacist there are two simple solutions

• e-scripts/faxes for all scripts that fall under the CMS guidelines. You know for darn sure that the prescriber knows who the payor is. Require the scripts be issued this way.
• denial of payment to the prescriber if they issue a prescription that does not meet the CMS guidelines. Hit them in the pocketbook instead of the pharmacist/ pharmacy. What incentive does the prescriber have to spend extra money on tamper-resistant prescription pads if the pharmacist/ pharmacy are the ones being hit with the penalties? My guess is that it would take two billing cycles for the prescriber to get new pads if they are denied payment.

* * * * *

We like to complain about all of the rules and regulations that have been dumped on us over the last several years. Poor, poor pharmacist. Look at all the non-pharmacist stuff we have to do. I didn't go to school that long to be the Sudafed-cop? I'm as guilty as the next pharmacist when it comes to this. Sadly, when we get the faxes about the proposed rule changes we shrug our shoulders and drop the fax in the trash. What good will it do to call and comment on the proposed rule changes?

Maybe it's time that we quit whining and put on our big-boy pants. When you get that fax or email, make the call. Maybe call two or three times. Take a little bit of personal ownership of your profession. It's easy to whine and complain. As long as we, as a profession, allow others to dictate how our profession is being practiced, things won't change.

Plan Limitations Exceeded, Part Two

Thanks to the wonderful internet and Twitter, a fellow pharmacist has led me to a story on CVS Caremark that sheds more light on some of their possible business practices.

Follow the link to this story at the NCPA site. Not that all of us didn't know this all along.

Pharmacist's Day Off

The local media had been promoting the most recent "snow storm" for about three days. Some comparing its track to the blizzard of 77 or 78 (I can't remember exactly when it was, but I do remember it).

The pharmacy was busy leading up to the start of the snow. Then it was quiet. Snow was blowing. Not much visibility. And I got to work the closing shift. Since I live 27 miles from my pharmacy, I was looking at a potentially dangerous drive home. The road has several tight turns on hills. It's a fun drive in the summer. Not so much in the winter.

Well the drive was less than eventful. It took exactly three minutes longer than normal to get home. The "storm" produced about three additional inches of snow on the ground at my house. But school was already cancelled for Friday.

So what do you do with three kids on a Friday in January? Go to the park. It has the best hill around for sledding. We loaded the kids up in my truck and headed over to the park.

The snow wasn't that great for sledding, but after a few trips down the hill it started to pack down and we were able to get some speed. That's when I decided to try my luck on a snowboard. We bought our second child a $40 snowboard at Target for Christmas and this was our first opportunity to use it.

What you are about to watch may be disturbing. Please, do not let any small children view the following video. It was recorded on my fifth or sixth time down the hill.







We live a couple hours away from the nearest ski area. I think we might be taking a little road trip on one of the upcoming weekends.

Plan Limitations Exceeded

How many times a day does that message pop-up on your third-party rejections screen? Usually it happens when you are trying to submit a claim for a 90 day supply when the plan only pays for thirty. Or when the prescribed dose takes the medication over the plan's daily limit, which is sometimes resolved with a quick call to get the override.

Other times it pops up when a maintenance medication is trying to be filled at the local retail pharmacy and the patient's plan requires mail-order after the first two fills at the local pharmacy. I get that. I expect that..... in March or April.

Not on January 2.

I had that message appear on one of the first prescriptions that I filled last Saturday. And since then about two scripts per day. A little bit ridiculous.

Oh wait, I forgot to tell you what the secondary message said:

-Please have customer call CVS Caremark 888-769-9030

Now you know what's going on. Even though my pharmacy is contracted with CVS Caremark, I'm only allowed to fill one prescription for my patients, then I have to tell them that they need to either go to the CVS that is two miles away or start mail-ordering. Somehow this doesn't seem right to me.

But stuff like this has been going on for years. And it's not exclusively CVS Caremark.

This is what happens when insurers of prescription medications are permitted to be providers. They set up little rules that force the patients to use them. Want to use a non-preferred pharmacy? No problem... copay will be doubled... if they allow you to use the non-preferred provider.

A year or so ago I called an insurance company to see how I was being reimbursed for a particular medication that I felt our pharmacy was being low-balled on. I wanted to know which formula was being used.

Federal MAC-plus?

AWP-minus?

AMP-plus?

GEAP?

I think it was the insurance company's MAC-plus list, because I couldn't get the math to work out using any of the other formulas that were included in our contract. I asked for a copy of the insurer's MAC-plus list to be emailed to me.

No.

Proprietary information.

So here's where we are. Insurance company (who is also a provider) gets to pick and choose which reimbursement levels the contracted pharmacies receive. They won't let us see the list of medications that are on each list. We just have to trust them.

I wonder if the reimbursements are also based on NCPDP numbers. Maybe the locations that are affiliated with the insurer get a little bit higher reimbursement levels. Competitors get a little bit lower levels. Hmmm.... I wonder how the insurance company's profits are doing?

Just some things to think about.

* * * * *

This is not an indictment of CVS Caremark. They are the national-level player that everybody can identify with. I personally think these practices occur more frequently at insurance companies that operate on a local/regional level where they hold a significant market share.

APhA claims MTMs as a win for pharmacy

The APhA is basically claiming a victory for having MTMs included in both the House and Senate versions of the health care bill. They claim a new mission for the profession grounded in MTM (this from their Top 10 News Stories of 2009 segment of the January 4 pharmacist.com FocusXtra email).

Well I've been making a few calls and sending out some emails to see how easy it is to get signed up as a medication therapy management provider with the Medicare D plans that operate in my state (Ohio). I'm doing this because my current employer is not really interested in the whole MTM-thing, which I can understand because at my previous position we had two or three MTM cases over a three year period. Not exactly a money-maker for the drugstore.

I'll let you know the results of my inquiries.

As it is now, the APhA seems as connected to the the real practice of pharmacy as my yellow lab who is sleeping on the floor right now. I've got an email in to them as well. Since my previous communications with them have been met with a lack of response, I'm expecting the same level of concern from them about real pharmacists as I have seen in the past.

In the meantime, if you work in a pharmacy that has actually been able to make MTMs a viable business venture let me know (government clinics and academia are not viable businesses). I would love to know how you are doing it. Shoot an email off to ericrph@msn.com .

If you are from the APhA, email me as well. We're all trying to advance the profession.

The apple doesn't fall far from the tree

Not too long ago I came home from work after a 10-6 Sunday at the pharmacy. Wasn't a difficult day, but it felt good to be home.

My fourteen year-old son shared something that had happened to him at church earlier in the day. I should mention that our church averages about three thousand people per Sunday. It's the largest church in our area. Very easy to miss people in the crowd.

Anyhow, between services a 70+ year old woman walked up to him and asked him if his dad was the pharmacist who worked at XYZ Pharmacy.

My son answered yes, wondering where the conversation was going.

She then proceeds to inform him that her shoulder had been hurting for several days and asked my fourteen year-old what she should take.

Now my wife is used to questions like this. So are the spouses of our physician friends.

But to an eighth-grader?

He asked her what she had tried (nothing) and then told her Tylenol or Motrin before running off with his buddies.