Tuesday, August 31, 2010


I'm suffering thru a mild case of writer's block. I know what I want to post, but can't quite express it in a manner that I am happy with.

So I've put up a little poll on the side. Please take a moment to vote. I just want to see what other pharmacists are thinking about pharmacist reimbursement for professional services.

Also, I encourage you to leave comments on the posts that appear on this blog. I see the number of visitors that this blog receives and less than one percent of people who visit the blog leave a comment.

Comments help me in the creative writing process. I write this blog to try to get pharmacists to think outside of the box. Our profession has been in the same rut for 30 years and we need to get some fresh ideas on the profession. Your comment may be the one that helps somebody develop an idea that will change our profession for the better.

Also, I see who visits the blog. Corporates and organizations. They are watching the social media for our thoughts and ideas. Share them.

But if you don't share your thoughts.....we'll be in the same place twenty years from now.

I guess there's one more thing... if you like one of my posts, share it. There are buttons at the end of each post, as well as on the sidebar of the blog, that enable you to share the post(s). Send the links to other pharmacists that you know. We need to get more pharmacists involved in dialogue as our profession moves forward.

Thursday, August 26, 2010

a-MUSE-ing memory...plus a bonus

These days, if a guy has problems getting Mr. Happy to rise to the occasion in the bedroom, all he has to do is pop a little pill and things will usually start to work. Many relationships have been saved due to the effects of Levitra, Cialis, and Viagra. Erectile dysfunction is no longer something to be ashamed about.

But not too long ago, the treatment options were a little more invasive. Proper administration was crucial to the successful use of the medications. I remember the counseling sessions where I showed many men how to inject their penises with alprostadil (Caverject, Edex). You could tell that the thought of sticking a needle in Mr. Happy didn't appeal to very many of the men, but the sex drive usually overcame the fear of the needle and the guys gave it a try.

But there was another alprostadil product.... M.U.S.E. The Medicated Urethral System for Erection. This was a small pellet that was inserted into the urethra to help the man achieve an erection. It didn't involve a needle, but it still involved sticking something into Mr. Happy. With the M.U.S.E. system, you needed to have a somewhat steady hand while inserting the suppository. I fielded several calls from men (and women) about the suppository falling off of the applicator that was enclosed.

(I know, the picture is not entirely accurate with how the M.U.S.E. applicator looks, but it achieves the purpose of displaying something being placed into the urethra of a man)

A few years ago, I had a 50-something male patient who was trying to recapture his youth. We'll call him Peter. Whatever the latest trend was, he was on it. Pierced tongue...yep. Tattoo on back of neck... yep. He had white hair, but it was colored. I think we called it piss-yellow. Anyhow, he was having his mid-life crisis. And I recall filling a prescription for him one day for the M.U.S.E. and him rushing out the door without being counselled. He was too busy. He'd read the info sheet when he got home.

One Saturday morning, Peter comes into the pharmacy. He was throwing a royal hissy-fit. Told me that the M.U.S.E. didn't work.

Apparently the night before, he was able to charm a young lady (at one of our local bars) and get her to go home with him. In his drunken excitement, he attempted to insert one of the M.U.S.E. suppositories. He was not successful. He told me that he had tried to insert it several times, but could not get an erection.

Then he reached into his pocket and pulled out the applicator. It was covered in dried blood. Peter had stabbed his urethra multiple times in an effort to get Mr. Happy to rise to the occasion.

Moral of the story: If you need assistance in getting Mr. Happy to help make you happy, you should read the instructions well in advance of any sexual activity. Maybe practice once or twice. Sticking a plastic applicator into the end of your penis is not something that should be attempted for the first time while in a state of drunken arousal.

Some of you may recognize this as a recycled post from my previous blog. So as not to disappoint, I'll add this extra snippet.

A gentleman stopped by Happy Drug World to pick-up his Viagra 100mg script recently. The copay was around 160 bucks for 8 tablets. Twenty bucks for each tablet.

His response when he heard the price.... that's a heckuva lot of money for less than 5 minutes of fun.

Now if I was him, that's not what I would say. Under five minutes of fun? That's not too impressive. It certainly didn't impress my cashier or technicians.

So here's my piece of advice for any man picking up a prescription for Viagra, Levitra, or Cialis. Since we all know that it costs about 20 bucks per encounter for the medication, the response that makes you look more manly is hey, that's less than a buck per minute. Cool.

Trust me. You will earn the respect of the entire pharmacy staff with that response.

Tuesday, August 24, 2010

The Dumbest Generation

Yesterday I went to our local mall with my wife and two of our three children to get some last-minute school shopping done. While the girls were looking at shoes, I ventured over to the bookstore with my son to see if there was anything interesting to read.

Personally, I love to read books on politics and history. So I was looking in that section. I found a book that I've been looking for since early in the summer, so I grabbed it. But in the politics section there was another book that caught my eye: The Dumbest Generation: How the Digital Age Stupefies Young Americans and Jeopardizes Our Future (Or, Don't Trust Anyone Under 30)

I didn't grab it....yet. But I will probably purchase it in the near future.

Just seeing the book made me think about the younger patients that I have interacted with over the last few years. Based on the title of the book and these interactions, I would tend to agree that they are the dumbest generation, but not necessarily because of the digital world.

When I think of the under-30 patients that I see on a regular basis, I don't have much hope for the future. When I factor out the antibiotics and asthma patients, what's left?

At Happy Drug World it's not pretty.

We've got fat fat fatties picking up their Type II diabetes and cholesterol pills. And these people are having children who are growing up in the same households where the main forms of sustenance are KFC, McDonalds, and Mt Dew.

Then there are the people coming over from the counseling center. Former and current heroin/meth/crack abusers whose brains are so fried that they are now almost comatose from all of the antipsychotic medications that they are on. Some of these people are taking doses that would knock an elephant out for a few days.

The other patients from the counseling center come in with their orders for clonazepam so they can feel drunk while working rather than actually being drunk at work. The old "side effect of my medication so you can't fire me" approach. When I see these people at the grocery store, there's usually a case or two of a not-so-fine alcoholic beverage sitting in their cart.

Besides these patients, we have all the people who are sad. On any given morning I dispense enough antidepressants that the entire town ought to be grinning ear-to-freaking-ear. I have my personal thoughts on why everybody is on a happy pill, but I'll spare you from them.

I could go on at length about all of the metronidazole, azithromycin 1 gram, you-name-it for your socially acquired conditions, but if you are in retail you know what I'm taking about.

And finally there are the people with anxiety and pain. Some many people under the age of thirty with anxiousness and pain. It would be interesting to see a report on the volume of prescriptions for Xanax, Vicodin, and Ultram that are dispensed to the under-30 crowd. It would probably scare the crap out of us.

The under-30 crowd has been raised in an environment of "if it feels good, do it". That has lead to a generation of people as described above.

Welcome to retail pharmacy, my friends. Where we get to interact with the dumbest generation on an hourly, if not more frequent, basis.

Thursday, August 19, 2010

Stop giving it away

Thank you for calling County Memorial Hospital Emergency Department. Please note, by law we are not able to give medical advice over the phone. If you are calling from a physician's office, press one. Pharmacies, press two.....

That's the greeting from the direct line to the local ER. I can't confirm the validity of the statement that it's against the law for them to give advice over the phone. But they are on to something. If you can't make the effort to come in to see us, we're not giving you any information.

They aren't giving it away.

Hmmmm..... we give it away all the time. Why?

Ever call your personal physician with a question about your own medical condition? How many times does the receptionist say that you need to come in to be seen? In my area if you don't pay, the doctor has nothing to say.

Yet we give away information all the time.

Sometimes face-to-face. Sometimes over the phone.


If we are the medication experts, why do we give it away? Because we always have doesn't cut it any more. Experts in other medical fields don't give it away.

We need to change our way of thinking. We are the most accessible health care provider, but that doesn't mean that we need to be the free health care provider.

Several years ago I worked for a company that was toying with the idea of pharmacists billing for our OTC consults. We were going to carry tear-off sheets in our jacket pockets to document the OTC consults and bill for them. The only issue was collecting the insurance information. Asking for an insurance card before dosing Tylenol was odd. The idea didn't survive.

That was then, this is now.

We need to be compensated for each and every time that we utilize our professional skills. I'm going to throw this out there and maybe somebody who is a better position than me can develop this idea.

Each person should have a medical card. Similar to a credit card with the magnetic stripe, but it should contain the person's insurance information. For medical, dental, and prescription purposes there would be no more entering of insurance data. A simple swipe of the card on a card reader would populate the required fields on a computer's insurance screen. (Solves the standardized card format issue right there)

Everybody has one. Even cash customers. You must present the card at each and every transaction surrounding medical care. No card, no care.

For pharmacists, before giving any OTC advice we swipe the card on a PDA. Insurance information is captured. After the consult we record the details of the exchange and submit to the insurance company. Check comes directly to the pharmacist. For the uninsured, we are able to write off the consult on our taxes.

And there you have it. Step one for taking back control of our profession... we don't give away information for free.

Tuesday, August 17, 2010

It's not Skittles, Giant Eagle

After writing my post on the total devaluing of the profession of pharmacy by Giant Eagle's free diabetes medications, I felt that I needed to have a follow-up post.

I thought about continuing my thoughts about giving away the profession in a time when we, as pharmacists, are looking for revenue streams that are separate from the drug product. You know, billing for our knowledge. In case you have been asleep for a while, we are the medication experts so we ought to be compensated for knowledge. If I ask one of my attorney friends a legal question, I know that I'll see a bill in my mailbox in a few days. Why shouldn't we do the same?

I thought about writing on the effects that the free medications will have on MAC drug pricing, especially by insurers who have their own MAC list that may include more medications at lower reimbursement rates that the federal MACs.

But then something came to mind as I was driving home from school shopping with my kids.

This is outright professional negligence.

I had a theory to back up this thought, but I needed to confirm my suspicions. So during a slow moment during Monday's pharmacy fun, I placed a call to Giant Eagle that is close to my home. Ten minutes later, I had my answer.

* * * * *

Let's jump back a few years to a piece of legislation that everybody in pharmacy loves....OBRA '90. Remember the part where pharmacists must perform prospective DURs?

Since OBRA '90, we have become accustomed to the DUR rejects that are returned by insurance companies. Most of the time they are a pain in the butt, but occasionally they alert us to a severe interaction with a medication that the patient is getting filled at another pharmacy. It could be at the Walgreen's down the street or the mail order facility in New Jersey, but we are alerted. We, as pharmacists, can then discuss the issue with the patient and use our professional judgement before dispensing the medication to the patient.

* * * * *

Now back to Giant Eagle.

In my discussion with the pharmacy staff member at my local Giant Eagle, the employee said that the prescriptions are basically entered into the computer and billed as cash, avoiding transmission to the insurance company. Makes sense from a business standpoint since the switch fees will be avoided.

But by not submitting the claim to the third-party, part of the prospective DUR process is being missed. The pharmacist at Giant Eagle is not going to be able to utilize the third-party's DUR process to check for interactions with medications filled at other pharmacies. To me, it looks like the grocery boys are putting the safety of their pharmacy patients at risk in order to get them into the store to but more Pop-Tarts and Doritos.

I guess that's their choice. They can side-step that part of the law. Maybe say that they asked the patient if they were taking any other medications and the patient denied taking any other meds.

But I do have a problem when that patient who had their diabetes medication filled at Giant Eagle comes to my pharmacy to fill something else. I'm going to ask about their other medications and get the I don't know or the the little white ones response. So I'm going to count on their insurance company to help me on the prospective DUR.

Oh wait.....

I won't have that available to me because Giant Eagle didn't submit a claim to the insurer. They billed it as cash and bypassed the insurance company's collection of the patient's medication history.

Because of their little marketing gimmick, Giant Eagle is endangering the health and well-being of our mutual patient. They are risking the lives of people in order to get them to buy more Jif peanut butter. I can't wait to see the first lawsuit filed over this one.

The non-pharmacists who are currently making decisions for pharmacy need to step back and realize that the products we deal with are powerful. They have the power to keep otherwise unhealthy people alive for years longer than the person may have been able to live if they didn't have the medication.

They also have the power to end a life with a single dose.

That's why trained professionals who are medication experts are the people who handle these products. That's why we need to have a complete medication history available to us. That's why the insurer's DUR is a valuable tool for us when patients jump from pharmacy to pharmacy.

We're not playing with Skittles behind the pharmacy counter.

Friday, August 13, 2010

Psych disorders in kids, made easy

I'm working on a follow-up to my post on Giant Eagle, but I haven't had the time over the last couple of days. So in the meantime, enjoy this post and see which of your patients could pass as Piglet, Pooh, etc....

Also, check of APhA CEO Tom Menighan's post on Giant Eagle's free generic diabetes meds. He has some nice points.


Tuesday, August 10, 2010

Giant Eagle....destroying the profession of pharmacy

If you haven't heard it yet, the profession of pharmacy has taken another hit by a chain to destroy and devalue the role of pharmacists.

Giant Eagle, a grocery chain based out of western Pennsylvania, has decided to distribute a handful of diabetes medications to their Advantage card members for free. This follows in the footsteps of their program to give away certain antibiotic prescriptions for free.

If this doesn't piss you off as a pharmacist, I don't know what would.

We have a grocery store telling pharmacists that the value of their PROFESSIONAL EXPERTISE is ZERO DOLLARS. Actually, it's less than that when you factor in the cost of medication, vials, etc.

If you are a pharmacist with Giant Eagle, you should be raising holy hell over this move. I don't work for Giant Eagle and I feel offended for the pharmacists that work there.

In a time when pharmacy organizations are trying to get insurers and the government to see the value of a pharmacist's expertise in medication therapy and compensate us for this expertise, we have a bunch of jokers over at Giant Eagle saying Hey, the pharmacist's expertise is work diddly-squat.

Back when all of the $4 generic programs rolled out, pharmacists cried out that the professional services offered by pharmacists were being devalued. Giant Eagle views these services as having absolutely no value. After this move, I don't see how any self-respecting pharmacist could continue to work for Giant Eagle.

Out of curiosity, I visited the news pages for the Pennsylvania, West Virginia, and Ohio pharmacist associations. I didn't see a single mention of this abomination that Giant Eagle has implemented.

The pharmacist associations should be screaming from the rooftops about this. This grocery chain attempting to dictate the course of OUR PROFESSION.


The course of pharmacy should be determined by PHARMACISTS, not banana pushers.

Every pharmacist should be speaking out against this. If you sit back and stay quiet, you are saying that you don't care that our profession is being hijacked by freaking grocers.

It's time to grow some balls folks. Pharmacists need to speak up in opposition to this move by Giant Eagle.

YOU are the voice of pharmacy.

You can't count on a few voices on Twitter or blogs to be the only voices speaking in opposition to this. Every pharmacist should speak up.

APhA..... you're the organization that needs to lead on this one. The profession is being attacked by some bagboys in PA. It's time to step up to the plate to show those of us in the retail world that you care about us. If retail pharmacy devolves into free drugs for everybody, you won't need to worry about MTM and immunizations because there won't be a snowball's chance in hell that anybody would pay for anything offered by a pharmacist.

State organizations... get on your state legislators. Get something worked into the law that guarantees that pharmacists must be compensated for their professional expertise. A salary doesn't cut it anymore. We need to be paid for our expertise on each and every prescription that we handle. Check out the idea at the end of one of my previous posts and run with it.

Tuesday, August 3, 2010

Texting in the pharmacy

I looked at some of the search terms that were sending people to this blog recently and saw something that jumped out. Somebody had Googled pharmacist was texting. It was linking to the Born yesterday post, but it reminded me of something that happened recently.

As a pharmacist, I get medication-related questions all the time from friends and family. I don't mind it because I want my friends and family to use their medication correctly. Usually the questions come to my cell phone as a text message. My friends and family don't know my work schedule, heck I hardly know it these days. And they don't know my work number. Why should they? I can be reached by text.

By some weird thing with Verizon, I can receive texts anywhere in my pharmacy, but I can only use the voice features of the phone if it is on speaker, sitting between my computer terminal and the phone. And that only happens when the wind is blowing just right. Basically no voice coverage in the pharmacy and in the 15 feet surrounding it.

Back to the story. Several weeks ago I had a patient come to the pharmacy with an ER prescription for a C-IV. The ER physician had caved in to this person and ordered 10 doses so their three hour wait in the waiting room was worth it. My technician had given the patient a time that the prescription would be finished.

The patient was one of those who lingers a bit too close to the pharmacy. Made a few comments about the length of time that it was taking to fill the prescription. Now we are a busy pharmacy. Usual wait times are 25-30 minutes. The patient started complaining at about the third minute.

During this time, I received a text from one of my friends. She has a little girl who is two months younger than my daughter. Her daughter has an autoimmune disorder and is taking some anti-rejection medications. Over the last few days she has had splitting headaches and has been hitting herself on the head, trying to beat the headaches out. The neurologist has wanted to start her on topiramate, but my friend wants to be sure that the headaches aren't simply a side effect of one of the medications her daughter is already on before adding yet another medication.

Since the ER patient's prescription has not been brought to me for the final verification, I have been texting with her to get more info and try to get an answer. That's when the ER patient said something to the effect of if the pharmacist wasn't texting. The ER patient had a bit of a chip on their shoulder.

Now it takes a lot to get me mad. I understand that a lot of the people coming to the pharmacy are sick and don't feel well. They may have just come from the ER after waiting several hours and just want their medication so they can start to recover from whatever ails them. When you are a seeker who is griping about the wait time for your prescription (when it is still 15 minutes before we told you your prescription would be ready) and then make a comment like that, I tend to get angry a little bit quicker than usual.

A few minutes later the ER patient tried to look over the counter as I was taking some phone-in prescriptions to see what I was doing. That's when one of my techs told the ER patient to step back and that the prescription would be finished at the time we had stated. Somehow right after that, the technician who had the ER patient's order got tied up on the phone and wasn't able to complete the prescription until right before the promised time.

I verified the prescription and called the patient over to the counseling window. I informed the patient about the medication, then informed the patient that the texting I was doing was with the mother of a five year-old girl who has been in extreme pain for the last four days. That I was putting the health of a five year-old girl above that of an ER drug seeker. That I didn't appreciate the attitude, and a few other choice words. The ER seeker took a step back, tail between their legs.

Looking back, I probably could have handled the situation a little more professionally. But I don't regret my actions. If I have my BlackBerry out in the pharmacy and people are waiting on prescriptions, I am either checking one of the medication databases on my phone or answering a question. If you pop off and gripe about the pharmacist texting, I just may have to beat you.

Sunday, August 1, 2010

Patient counseling

While exploring the pharmacist.com website the other day, I came upon an article from last December that quoted an article from JAMA. The article called for more pharmacist involvement in medical teams, specifically medical home teams. Sounds like a win for pharmacy.

But there was a quote that grabbed my attention. “Doctoral-level trained pharmacists would not count pills. They would counsel patients about complex polypharmacy regimens and spearhead interventions to eliminate medication errors...."

A couple things came to my mind. First, the author of the JAMA article basically says that all that pharmacists with bachelor's degrees can do is count pills. Blood starts to boil at this point. Maybe the JAMA author needs to spend a day shadowing a community pharmacist to see what we actually do.

Second, why can only doctoral-level pharmacists counsel the patient? Isn't the license granted to pharmacists with bachelor's degrees good enough? Did things change on me somewhere?

I will grant you that the pharmacists coming out today probably know more than I did when I graduated. That doesn't make them better pharmacists, it means that more is known about medications than there was known in the past.

But counseling patients isn't about your book knowledge. It's about communication skills. When you counsel a patient, your part of the dialogue must be tailored to the patient's level of comprehension.

To me it's interesting to see the difference in communication skills of the students who do their rotations at my pharmacy. I have had kids who could tell me the entire metabolic pathway of febuxostat (before it was even approved), but couldn't explain to a mother how to use an Aerochamber with her child's inhaler. I've had others who I wondered if they could pass the NABPLEX, but they could make our illiterate patients understand what each of their six medications was for and how to use them correctly.

To be an effective pharmacist, I believe that you do need to have contact with the patient at the retail level. Where you can see the patient's reaction to the price of their medication. It doesn't do Mrs. Smith any good if you can throw together a regimen of Coreg CR, Tekturna, Lipitor, Lovaza, and Januvia when she can't afford it. Sure, that may be the best regimen for her from a clinical standpoint, but she may only be able to afford carvedilol, lisinopril, lovastatin, and metformin.

In my opinion, an affordable treatment plan that the patient will take every day beats an expensive treatment plan where the patient skips doses every time. I don't think that it takes a doctoral-level trained pharmacist to do that.

It takes only one thing....a Registered Pharmacist.