Thursday, February 18, 2010

Too much

That's too damn much. I just won't take the shit.

Then patient storms away from the pick-up area. Boy, he's shown us. He's a big boy and isn't going to take his medicine.

Most of the time, I don't care if a patient picks up their medication or not. I'm not the one with the illness that required the call to the doctor in order to get a prescription to clear up a common cold. Heck, thirty percent of our return-to-stocks are antibiotics that weren't picked up.

But when the medication is for a chronic condition, I tend to care a little bit more. Based on the patient's behavior, I may offer to call the prescriber to see about a more reasonably priced alternative. If you act like an adult and can have a somewhat intelligent conversation about the options that are available to us, I will do my best to help you out. If you behave like a two year-old and make a big scene, don't expect a lot of help from me. I didn't select your medication (the doctor did) and I didn't set your copay (your insurance company did).

This scenario plays itself out several times a week at the pharmacy. Normally it doesn't phase me. I help some of the people while letting the ones throwing their tantrums storm off. But lately I've been starting to get mad, at the people who just won't take the shit.


Because they are the older patients who get their medications covered by Medicare Part D. These patients just had a stay at one of our local hospitals where they received excellent medical care. The physicians and medical staff stabilized the patients' conditions to the point that they can return to a normal life in American society. The patients have been returned to health because Medicare has footed the bill for the hospital stay.

So now, when the responsibility for medical care falls back onto the patient's shoulders in the form of an elevated copay and the patient decides that they don't need the medication, it makes me mad.

But it's not surprising. The people who are covered by Medicare have grown up in a society that has promised to take care of them when they are old. Social Security will send you money, Medicare will cover your medical issues. These people have basically been told for the last 45 years that everything would be taken care of, that the government would take care of them once they retired.

Part of me feels bad for the patients. But there also has to be some personal responsibility involved. If a patient is not willing to pony up fifty bucks for the copay on their steroid inhaler, why should I have to pay for the ER visit and subsequent hospitalization when the patient's lung condition goes haywire and needs to be stabilized.

I don't know what the answer is. I have some ideas, but they would be seen as being cruel. One of them is to set up a database that records the discharge diagnoses for Medicare/Medicaid patients, as well as the discharge prescriptions. If the patient is admitted again within six months for a similar diagnosis and they have not filled or refilled their prescriptions, tough luck Charlie. It's cruel. But I'm getting tired (as a taxpayer) of footing the bill for people who have no interest in taking responsibility for their own health care.

Of course part of the problem could be avoided if the prescribers would consult with pharmacists about the costs of medications. Hospital pharmacists (I'm talking about those of you on the floor) need to step up to the plate on this. It doesn't matter if you recommend medication X for the patient if they can't afford it. Maybe you should (gasp) call the patient's insurance carrier before they are discharged to make sure the medications are covered and find out what the copay would be. If the patient isn't able to afford it, you could recommend an affordable alternative. Then a lot of the noncompliance could be averted.

I guess that I'm just tired of being the bad guy who gets stuck in the middle. All I'm trying to do is provide excellent patient care in a retail setting. But instead I'm the mean pharmacist who charges too damn much for the medications.


The Redheaded Pharmacist said...

Amen Eric. I've actually described retail pharmacy like "running a daycare" sometimes because of the way grown men and women act sometimes. And what really bothers me is when an adult acts like that with their kid standing right next to them. They are basically showing their children that it is ok to act like that and it is acceptable. It really irritates me to no end. Of course if you as a customer are willing to act like a civilized adult then I'll go out of my way to help you resolve any problem you might have with a prescription. People need to learn that bad behavior has consequences. The problem with that is that by the time you are an adult shouldn't you have already learned that lesson? I would hope so.


Unknown said...

Same scenario this week at my pharmacy.. Tuesday morning:refill of Xopenex unit dose copay comes up $104 and change. Original rx (and only time filled) from April 09 had a copay of $50.00. Patient's husband throws a fit at the counter--we are never to pay more than $50.00...blah, blah, blah... We suggest maybe his plan has changed....No, no, not supposed to may more than $50...If he wouldn't have been such a jerk, I would have offered to call Aetna. He leaves the rx, comes back today to pick it up...Guess what? His plan had changed!! Really? Really? Still waiting to hear "Sorry I acted like an idiot"--not holding my breath for the you were right.

pharmacy chick said...

Eric, it happens here all the time, and it doesn't seem to matter the socioeconomic group the patient is in either. Had one guy recently who didn't like his $150 copay (3 x $50 monthly) 90 day supply. "Well, I'll just go home and die then". he stammered. Well ok then. What did he expect me to do? give it away free? I didn't write the script. I didnt' buy his insurance.

Anonymous said...

As a pharmacist in a small hospital, there is some sympathy, but not as much as some might wish for.

Frequently, in our critical access county hospital it is difficult to even obtain an up-to-date medication reconciliation record when the patient is admitted, due to a number of different kinds of reasons: polypharmacy (including mail-order), not taking the medications or not taking them properly, no regular doctor. I usually call one of the patient's pharmacies to try to figure out what the previous therapy was, but many times the history is incomplete and there isn't even updated allergy information.

In my state we rely on INSPECT for controlled-substance records in retail, but there's no way we could know this in the hospital, since we are not set-up as a retail pharmacy. So, our information about a patient's insurance coverage would be the last thing we would have access, or be in our best interest to try to keep track.

Our hospital staff is minimal. Ideally, we would review patients' admitting information, but admitting nurses conduct the interview. We pharmacists never see a discharge sheet, so have no idea of what the patient is dismissed on. This is not a major problem since all the docs in the community have privileges and we're pretty familiar with what the docs write.

There are some drugs on the $4 list not on our formulary. It is in our best interest to maintain a facility corporation formulary especially when patients are transferred to specialty hospitals within in our hospital group. We keep our formulary closed and small as possible.

Local docs adhere to the hospital formulary as they all are part of the hospital. We live in a depressed community. If patients get fancy-dancy drugs they're usually hand-dipped from a physician's sample supply, and community docs are well aware of what their patients can afford, so there's no way that the doc is going to send a patient home on something expensive from our county hospital.

Hospital pharmacists input is probably more significant when patients go home from a specialized tertiary care facilities like Mayo, Cleveland Clinic or IU Med Center. I wonder if the discharge planning committee has a pharmacist on it to help monitor take-home med prescriptions.

Seamless transfer from retail to hospital is not; there are problems with poly-pharmacy, obtaining meds from mail-order (don't ever try to call one of these places for information--it's not going to happen!), patients that don't take their meds (our social worker refers a LOT of patients to the local skilled nursing care facilities), and patients that are so poor that they don't get consistent therapy, plus the simple fact that hospital pharmacy has no knowledge of what insurance plans would cover, or on what meds the patient will be discharge home.

I have always, always, thought it would be worthwhile if these reconciliation records could travel from retail to hospital to wherever, in the SAME format. When I first started following up with patient home supplies a long time ago, I even got a lot of flak from within the pharmacy department because we were going to be liable if we discussed patient therapies 'outside' of the hospital.

A single-payer health care system might provide involved a measure of consistency. Apparently a lot of pharmacists decry universal health care.

Jennifer said...

I feel you on this. At least on Medicare they're paying more of the inhaler than on Medicaid. I have numerous patients that refuse to give up smoking and fill every month like clockwork: Atrovent, Spiriva, Advair, Proair, albuterol nebulizer soln, etc. All on Medicaid. If we're lucky a $2 copay on some of them. The $2 will cause moaning and screaming, but the cost of 4 cartons of cigarettes doesn't phase them. I want to scream, "Quit smoking and then you won't NEED thousands of dollars of breathing aides every month! Arrrgh my taxes!"