Friday, December 23, 2011

Twelve Days of (Pharmacy) Christmas

Stolen from a Twitter feed from @_RxLauren

  • Twelve hours standing
  • Eleven early refills
  • Ten screaming customers
  • Nine benzo scripts
  • Eight a$$hole doctors
  • Seven drive throughs beeping
  • Six Plan B pick-ups
  • Five prior auths
  • Four cash narcotics
  • Three fake prescriptions
  • Two tripping junkies
  • And a pharmacist who hates her job.

Merry Christmas!

Tuesday, December 6, 2011

Frogger, RPh

Have you ever tried to boil a live frog? Just throw the frog into a pot of boiling water. It doesn't work because the frog's survival instincts kit in a it will try to escape. If the water isn't too deep, it will be able to leap out and survive.

But if you put the frog in the same amount of lukewarm water and gradually increase the temperature to a boil, the frog is not able to detect the temperature changes and will be boiled alive.

I've heard this several times over the years without thinking much about it. This past week, the president of our facility shared it during a meeting of our management staff and a thought immediately jumped into my head.

This is the world of retail pharmacy. Pharmacists are the frogs.

If you think about how the world of retail pharmacy has evolved over the past 20 years, I think it's easy to see how the pharmacist is getting slowly boiled. Many factors have come into play that are cranking up the heat on our professionals in the retail trenches.

Let's take a look at some of them. While in and of themselves they aren't necessarily bad (in fact some are good), the combined effects of all of these have turned up the heat on community pharmacists.

  • Third-party insurers. These initially helped level the playing field for pharmacists since patients would pay the same price wherever they chose to fill their prescriptions. However the ever-decreasing rates of reimbursement have driven many pharmacies out of business. And those that remain must fill more scripts to bring in the same dollars.
  • OBRA 90. Mandatory counseling, DURs, etc for certain patients. While these are good, there was no increase in reimbursements to hire additional staff to safely fill the prescriptions. Rather than ensuring that every prescription would receive its due attention, I think that it can be argued that the pharmacist has been legislatively forced to have interruptions in their work flow in order to offer the required counseling. And what passes as counseling falls far short of the intent of the law.
  • Drive-thru pharmacy. One more drop-off and pick-up area. Usually without additional staff (or reduced staff after the first three months).
  • Gift cards for transferred prescriptions. More phone calls to distract the pharmacists from their primary duties. And one more place where an error in communication can occur.
  • Pharmacy-initiated refill requests to prescribers. While this may help with compliance for some patients, it adds another uncompensated task for the pharmacist to oversee. I'm sorry, but responsibility for refills should fall upon the patient. It's no surprise that our patients don't take ownership of their health because they aren't asked to do anything other than fork over their copay.
  • Immunizations are good. The interruption to workflow is bad. Quotas on immunizations (which I have heard rumors of) are unsafe.
  • Auto-refills (aka predictive refills). Similar to the refill requests. Good intent, but patients need to be responsible for their own health. In my experience, about half of the prescriptions that my retail pharmacies filled through these programs were returned after 7 to 10 days. The process of returning the prescriptions is just as, if not more, labor intensive as the original fill. More uncompensated work for the pharmacists.
  • $4 generics. Affordable medications can increase compliance, but the amount of staffing hasn't grown to offset the increased workload. More scripts, less help. Not good.
  • 15 minute guarantees. Only to be outdone by 10 minute guarantees. Sure. Why not? While we're at it, let's have corporate call to find out why it's taking so long to get the scripts out the door. One of my friends recently had a corporate person call to inform her that corporate was looking at the video cameras and the pharmacy pick-up lines were too long and wanted to know how she was going to rectify the situation.

The pastor at my church often asks us if we are being a thermometer or thermostat in our community. The thermometer simply is a reflection of the environment. The thermostat sets the environment.

In order to effect any change in the retail environment, we need more pharmacists to be thermostats. Speak up when necessary. Promote positive change for the profession.

Because if we continue to just be thermometers, we're a bunch of boiled frogs.

Tuesday, November 1, 2011

David Snow U

Unless you've been under a rock recently, you would know that Medco's David Snow caused quite a ruckus lately with his comments about retail pharmacists. I haven't looked into his comments, and I'm not going to. I think that the reaction that has already taken place gives me a good idea of what he said.

One question comes to mind...if retail pharmacists are so inaccurate, why does Medco have their name on the yet-to-be-accredited college of pharmacy at Farleigh Dickinson University? Do they somehow have the ability to train human to be 23-times more accurate than we currently are?Those are the figures that he quoted when he spoke at the Cleveland Clinic.

The Accreditation Council for Pharmacy Education hasn't accredited the college...yet. Corporate money will help the ACPE turn a blind eye to this slap-in-the-face to pharmacists.

But then again, Farleigh Dickinson could make a stand against Medco as well. Isn't a bit hypocritical for a pharmacy college to accept funding from a company that is trying to decrease the number of pharmacists out there in the retail setting? We know that won't happen either. What college is going to turn away people willing to pay $40,000+ per year for 4 to 6 years to enter a career field that is already saturated?

But then the answer came to me. I know what student the pharmacy college at Farleigh Dickinson is trying to attract. I don't want to stereotype the student who would attend this school, but I will share a picture of what the initial students graduating from this school may look like.

The ideal FDU Medco College of Pharmacy graduate looks like this....

Tuesday, October 25, 2011

Even if the truth hurts

Several days ago I stopped by a local pharmacy on my way home from the hospital to pick up an item for my wife. While waiting in the checkout line, I overheard the conversation of two senior women who were ahead of me. One of the women was telling the other about her husband, who was hospitalized due to a diabetic foot ulcer. She said that he had known about the sore on his foot for quite a while, but he had chosen to ignore it. Upon admission, the ulcer had reached through all of his tissue and the bone of his heal was exposed.

Upon hearing this, most people would think “poor guy, hope it heals”.

But that wasn’t my thought.

Maybe my years in community pharmacy have jaded me. Maybe seeing patients admitted repeatedly for the same diagnosis has hardened me since my move to the hospital setting a few months ago. Whatever the reason, my sympathetic side took a backburner to my practical side. My thought was a simple one.

This admission was totally preventable.

Seriously. It is 2011 and we are living in the United States. There is no reason that anybody should be admitted for a diabetic foot ulcer.

We have the best medications to control blood glucose levels. We have at-home testing machines that can tell you what your blood sugar (and hemoglobin A1c) levels are. We even have little mirrors on the ends of poles to help diabetics inspect the bottoms of their feet.

We have home health care companies that go to patient’s homes three, four, even five times a day to help people take their medications. There are social services that come into people’s homes to help with meal preparation and housekeeping.

We have a vast amount of information available to us over the internet. With a few keystrokes we can find out about our medical conditions and how to stay healthy. If your physician is tech-savvy, you can have access to him or her with a few keystrokes on your cellular phone.

With all of the advances in technology and medicine, there really isn’t a good reason that I can think of as to why somebody should be admitted for a diabetic foot ulcer that has reached the bone.

Other than patient apathy.

The hospital administrator side of me started thinking about how, in the near future, hospitals aren’t going to get paid by Medicare for patients who are readmitted within 30 days for certain conditions. Even if the hospital does everything correctly, a patient who doesn’t care about his/her health is going to receive thousands of dollars of care for which the hospital will not be reimbursed. Diabetics who bounce back into the hospital because they can’t manage their disease are going to drain my facility of resources that could be used to treat patients who genuinely desire to get well. It makes me kind of angry.

Then there’s another side of me that wonders why nobody said or did anything. Why did this guy’s wife let the foot go untreated? Has this guy ever been educated about his disease? When was the last time this guy saw his physician? Is he taking his medications correctly? Has he ever talked with his pharmacist about his medications? Can he afford his medications?

These thoughts are running through my mind and I remember a comment that somebody recently left on one of my older blog posts. The jist of the comment centered around a thought that I had shared when a patient asked why they needed to be on a medication. My thought was “because you are fat, lazy, and need to exercise”. The commenter thought it was unprofessional of me to think like that, and who was I to judge.

Maybe I was wrong to think like that (even though I saw the grocery items that were in the cart). But then again, maybe I should have said what I was thinking. So much of our effort in pharmacy is dedicated to keeping the person as a customer rather than speaking to them as a patient. Are we doing our patients a disservice by sugarcoating our message? Sometimes being blunt is what is required to get the point made.

Would this woman’s husband have been better served if somebody had actually said “keep your blood sugar under control or you are going to get a nasty infection on your foot that may require amputation” Most people are afraid of losing body parts so that may have resonated more than “Jim, are you taking your pills right? No? Well you better. That’ll be $4.00.” When I worked for one of the chains offering $4 prescriptions, I didn’t have the opportunity to even have that discussion.

I did have a position at a regional grocery chain (where we filled 120-180 scripts/day) where I was able to talk to my patients. I got to know my patients and their families. And when warranted, I would be blunt with them. They understood that it was coming from somebody who cared for them and wanted to see them healthy. It has been three years since I left that position and I still get stopped at football games and swim meets by my former patients who thank me for how I helped them with their medical conditions.

I didn’t become a pharmacist to sugarcoat the truth to make people think that they are being healthy. If pharmacists want to impact the health of our patients, we need to be truthful.

Even if the truth hurts.

Thursday, September 29, 2011

MTM Workshop

In an effort to achieve my blog's goal of advancing the profession of pharmacy, I decided to post a link to a workshop that is being provided at the ASCP's annual meeting this November in Phoenix.

I was made aware of the meeting by one of the members of the ASCP Foundation following a recent post about the future of MTM. If you are like me, a mid-November meeting is really kinda last-minute. But if you have flexibility, it may be helpful.

To me, it looks like a "how-to do MTM" session. It does look like it has a little bit of info on developing a business plan. Personally, I'd rather attend a "how-to get your services paid for by an insurance company" session. I live in an area where people don't exactly have a spare hundred bucks of their income to spend on an MTM session with a pharmacist, so I'd like to hear from individual pharmacists who have successfully enrolled as a provider with an insurer.

For those of you who are interested, here's the link to the ASCP's page for the session.

Wednesday, September 28, 2011

The ASCP wants you.....

To help them out. Click here to link to a survey for long-term care pharmacies and consultant pharmacists. The results are sent to a third-party, who will in turn submit a report to the ASCP.

Wonder if they will give me a year's membership in exchange for the promotion of their survey and web-site?

Thursday, September 22, 2011

Thank goodness for United Healthcare

I've been hearing this commercial over the radio for the last several days. Each time that I hear it, I get a little bit more pissed off.

Pharmacists are being depicted, at least by United Healthcare, as idiots who can only catch a drug-drug interaction if the almighty insurance company alerts them.

Rather than promote themselves as the ever-present protective force in the prescription drug arena, how about running an advertisement to encourage your subscribers to pick one pharmacy and stick with it? You know, so your records are in one location instead of being scattered between Walgreen's, CVS, and Target?

Oh yeah, because you force your subscribers to use the mail-order service where they never even get to meet the pharmacist who fills their prescriptions. You promote the very practice by which you claim to be protecting your subscribers from.

Don't insult us, United Healthcare.*

*-this post doesn't apply only to United Healthcare, but to all insurers and pharmacy benefits managers who place profits first and patient safety second.

Wednesday, September 14, 2011

More concerns about MTM

The internet is an amazing thing. It allows us to share thoughts and ideas with a wide spectrum of people and receive feedback almost instantaneously. This is one of the reasons that I enjoy writing on-line. I receive emails and comments from people who I will probably never meet in real life, but we are able to share our experiences. Hopefully for the betterment of our lives and, since I write almost exclusively on pharmacy issues, our profession.

After my last post, I had a few people contact me to challenge the statements that I made. I appreciate this. It allows me to strengthen my argument if needed. It can also open my mind to points of view that I may not have considered. For today’s post, I’m going to address some of the issues that were brought up to challenge my thoughts on medication therapy management being the future of pharmacy.

First, let me remind you that I believe that pharmacists are not utilized to the fullest extent of their potential in the community setting. Heck, community pharmacists aren’t even being used for ten percent of their potential. That’s why the concept of medication therapy management is appealing. In theory it gives the community pharmacist the opportunity to utilize his or her skill sets to have a positive impact on the health of patient. That’s why we became pharmacists…to help people.

But the reality of the situation is that MTM isn’t going to happen. At least not to the level that pharmacists would like to see. Sure, there may be an individual here and there who is able to generate a revenue stream from MTM-style services. But when it comes down to it, insurers aren’t paying for the services. And if insurers aren’t paying, people aren’t going to use the services.

I’ll use the Diabetes Ten City Challenge to make my point. Now this was to be the national rollout of MTM services following the Ashville Project. I printed off a copy of the article that reported the results of the DTCC from the Journal of the American Pharmacists Association (J Am Pharm Assoc. 2009:49:e52-e60) and did my own analysis of the results.

Firstly, when the results were published, two of the ten cities didn’t have their data included in the results. For whatever reason, Chicago and Los Angeles didn’t get counted. So in effect we have the Diabetes Eight City Challenge.

To be included in the DTCC certain criteria were required:
· Participating groups had to be self-insured with a patient base of at least 5000
· Incentives for insured persons to participate were to be provided
· The insurer had to have strong internal support for the program
· The Ashville model was to be followed

I pulled some information from the DTCC website to see how many people took advantage of the programs. Only six of the reporting cities had data on the number of patients enrolled in the plans that took part in the DTCC. These six cities had approximately 43,200 potential patients. Not diabetic patients, just overall patients. From the eight cities that were included in the final statistical analysis, only 832 patients with diabetes started the program. And from these patients, only 572 completed at least one year and were included in the final analysis. That’s less than 2 percent of the insurer’s patients who took part in the program.

The insurers gave incentives for the people to participate. Things like discounted or free copays on their medications. No out-of-pocket expense for testing supplies or lab work. Credits towards their deductibles.

All of this incentive and less than two percent enrolled in the program. Granted, the data does not say how many patients were actually diabetic, but remember I’m using the number of patient who enrolled from eight cities divided by the number of eligible patients from six cities and I still come in at under two percent. People aren’t beating down the doors for these services like some would have you believe.

When I looked at the final results of the study, I wasn’t impressed. The DTCC did report that there was a savings versus projected costs. Not against a control group, but against the insurers’ projected costs for the patients. My fuzzy math skills calculated that the insurers expected the costs of medical care to increase 13.5 percent, but the actual increase in cost from baseline was only 5.3 percent. That’s how you can report cost savings of 7or 8 percent.

The claims of success for the DTCC were base on improvements on some lab tests. Wanna know what the improvements were? A1c dropping from 7.5 to 7.1. LDLs going from 98 to 94. Systolic BP dropping from 133 to 130. The average patient saw their pharmacist every other month for MTM services and this is the impact that the pharmacists had? Was it really the pharmacists’ interventions that had an impact? Or was it the impact of generic drug prices falling upon the release of Wal-Mart’s $4 list? Or how about some new medications that came out around the time of the DTCC (Byetta/ Januvia)?

We are basing the future of our profession on a couple of studies. Just two. Ashville and the Diabetes Eight City Challenge. Would you agree that the FDA approve a medication based on two studies? But you are banking on the future of your profession on two studies.

Another criticism of my previous post centered on my pointing out that only 27 percent of Medicare Part D plans cover face-to-face comprehensive medication reviews. The point was made that other health care providers are searching for methods to bill for these tele-medicine services. One point was over-looked. The physicians already have an established relationship with the patient. They have met face-to-face previously. They are simply expanding their access and creating another billable service. Billable service? Aside from three CPT codes that offer Level I reimbursements, pharmacists don’t have billable services. And even if we did have more billable services, insurers don’t recognize pharmacists as individual health care providers. After 20 years of pharmaceutical care/MTM, we are still seen as an extension of the building that holds the drugs.

I found an article summary online from the American Journal of Geriatric Pharmacotherapy on the impact of telephonic MTM. In a nutshell, telephone MTM did help resolve medication health-related problems, but did not have an impact on medication adherence or on total drug costs. That doesn’t make the case to me that telephone MTM has an impact on the quality of care delivered.

I receive messages from the APhA listserv for pharmacists who have completed the MTM training session. On July 27th there was a message asking for real-life examples of pharmacists who have been able to incorporate MTM into their business model for inclusion in a guidebook/workbook for MTM. One of the organizations championing medication therapy management has to ask for examples of pharmacists who have been successful at the professions future? Twenty years after Hepler and Strand and we are looking for success stories?

On August 17 the Center for Disease Control and Prevention announced that they were going to award the AphA Foundation a purchase order to “identify and engage a consortium of key stakeholders who have knowledge of, experience in, or can facilitate the adoption and implementation of collaborative medication therapy management policy” and also to educate policymakers. I could save the CDC a lot of money if they float a PO my way. I’d tell them to have CMS give us status as primary-care providers and about thirty billable codes and see the impact that we can make.

As a profession, we’ve sat around for the past twenty years hoping to get reimbursed for services that we can provide. It’s time that organizations that purportedly represent the profession either put-up or shut-up with regards to MTM. In the twenty years since Hepler and Strand advanced the idea of pharmaceutical care/MTM we’ve seen the profession devolve to a three-ring retail circus with a $4 charge.

As always, share your comments either here or as an email to me. I appreciate the feedback. We need to speak up as professionals, while we still have a profession to speak up for.

Friday, September 9, 2011

That's not what the doctor meant

when he said you needed to bring in a stool sample.

Tuesday, August 30, 2011

I hope I'm wrong about the future of MTM

As a pharmacist, it is my duty to be correct one-hundred percent of the time. Correct medication, correct strength, to the correct patient at the correct time. If I am not correct, there may be some serious consequences.

Well today I am writing to say that I hope that I am not correct with what I am thinking, but from what I have been reading and researching, I just may be correct.

What is it that I hope I am incorrect about? It’s the thought that medication therapy management (MTM) is the model for the future of pharmacy. I’m afraid that the profession has gone all-in on this one practice model before the cards have even been dealt. Let me explain.

For the past twenty years, pharmaceutical care/ medication therapy management has been touted to be the future of pharmacy practice. There have been a few projects that have shown how interventions by pharmacists can improve the quality of health care and decrease expenses for employers and insurers (Ashville, Diabetes Ten City). But these have not been able to be duplicated and rolled out across the country.

In fact, after twenty years all we have are three CPT codes that we can bill our services under, but the insurers and Medicare do not recognize individual pharmacists as providers of medical services. We are still viewed by the product that we dispense instead of the services that we provide. It has only been in the recent past that the profession has been able to get language written that provides for grant money for MTM services. No funding yet, just language that might provide funding.

So where does that leave us today? Right now the only MTM that is being provided (and compensated for) is to patients who are enrolled in Medicare Part D Prescription Drug Plans. When the Medicare Modernization Act was passed several years ago, one of the selling points to pharmacists was that we were going to be able to provide MTM services to the Medicare Part D patients. At least with this community pharmacists should be able to provide the MTM services to a segment of the population who should be able to benefit.

The 2011 CMS Fact Sheet on Medicare Part D MTM (dated 6-30-11) provides some insight on how the MTM services are being provided. According to the fact sheet, all of the Medicare D PDPs offer telephonic consultations. And 27 percent of the plans offer face-to-face consultations. Only 27 percent. That is sad. The Medicare D plans are not allowing their patients to receive MTM services from the pharmacists that they know and trust.

The service that is being compensated is a comprehensive medication review (CMR). For those of you who have never provided a CMR consultation, it’s basically a medication reconciliation with a Q & A session afterwards. After twenty years of hoopla, the future of pharmacy is a med-rec and a Q & A?

Since I began writing my blog, I have had the opportunity to talk with several national-level pharmacists who are in the know about MTM. Folks who are higher up the national organizations. From these conversations I have learned that there aren’t any pharmacists who have been able to create a business model that is able to stand on its own financially. I have talked to a couple pharmacists who have been able to bill for their services and collect enough from insurers to cover their salaries and benefits. But these pharmacists have done so using billing codes that are “incident to” physician services, not utilizing the CPT codes that have been established for pharmacists.

If you have paid attention to recent articles, medication therapy management hasn’t been talked about as a service to be provided by community pharmacists. It’s now being thrown in as the pharmacist’s role in the medical home models and accountable care organizations (ACOs). It’s almost as if the national organizations have realized that medication therapy management as it was originally envisioned isn’t going to come to fruition so now they are trying to find a way to incorporate MTM into the ACOs to they can say that they were successful.

Like I said at the beginning, I hope I’m wrong about this. I want to see pharmacists able to bill for MTM services as individual providers. I want to see pharmacists recognized as individual practitioners by Medicare/insurers and not as extensions of the buildings that they work in. I want to see pharmacists reimbursed for the knowledge in their heads, not the pills in the bottle.

By embracing medication therapy management as the future of the profession of pharmacy, it seems to me that the national organizations and the pharmacy educators have gone all-in on this before the cards have even been shuffled, let alone dealt.

Sunday, August 28, 2011

Master of Pharmacy Medication Therapy Management

University of Florida Online Master of Pharmacy
Medication Therapy Management

If you have questions about the online Master's in Medication Therapy Management, we invite you to join us for a live information session on August 30.

The session will feature program director, Dr. Karen Whalen who will discuss program curriculum, the demand for MTM providers, and the many benefits of earning your specialized degree in MTM. In addition, current students will discuss their experiences in the program, their goals after graduation, and how they are applying classroom skills into their practice.

At the end of the session, you will have the opportunity to ask questions of our panel.

Date: Tuesday, August 30
Time: 7:00 pm EST / 6:00 pm CT/ 5:00 pm MT/ 4:00 pm PT

Register Now!

Best Regards,

Your MTM Admissions Department


I received this email a few days ago. Anybody else?

I would call to find out the details, but I am already attending a workshop on Tuesday night. If you call in to find out details, please leave a comment here or send me an email to let me know what was said.

As an editorial comment, I find it interesting that a university is offering a Masters program in medication therapy management. Especially since insurers are not recognizing pharmacists as individual providers of MTM services.

Tuesday, August 16, 2011

MTM... The future of pharmacy?

Keep your eyes open. If you've read this blog long, you know that I believe in the concept of MTM.

But is it the future of our profession?

I'm working on a post that examines where we are with regards to medication therapy management. With my new position as director of pharmacy, I have kept busy with the duties of my position so I haven't been able to keep up with the blog entries.

But I'm still working on posts, just not getting them typed up. Like I said, keep your eyes open for my future posts.

Wednesday, August 10, 2011

I need counseling...seriously

Last week I developed a condition with my right eye. I had spent the weekend working in the yard, trimming the trees, pulling weeds. All kinds of landscaping/gardening activities. As Sunday evening rolled around I started to feel something in my right eye. I assumed it was some sort of allergic reaction since pollens typically cause me problems.

So I took some loratadine on Monday morning and assumed all would be well by the end of the day. After finishing a round of golf after work, my eye wasn't better. By the time I returned home, the upper eyelid of my right eye was swollen.

In between rounds and meetings on Tuesday, I was able to run over to one of the nurse practitioner's offices to have my eye looked at. The diagnosis wasn't an allergic response. It was cellulitis. The nurse practitioner decided to e-scribe an antibiotic for me.

Since our facility doesn't have an outpatient or employee pharmacy, I had to decide where to have my prescription filled. This was the first time in my career where I wouldn't be using my own pharmacy to fill a prescription. I decided to use the grocery pharmacy that I had managed a few years ago.

Being the responsible patient, I called the pharmacy to give them my new insurance information ahead of time. It would be four or five hours until I would be picking up my medication. The pharmacist on duty was one of my partners from ten years ago. We've always joked around when we run into each other. As we finished the call, I told him to make sure he had his whole counseling bit together because I needed to know how to store my medication and what to do if I missed a dose. We laughed and hung up.

After finishing at the hospital, I drove to the pharmacy to pick up my prescription. After paying for my prescription I asked about the counseling. Steve informed me that when I signed for my insurance, I was also documenting that I declined the offer of counseling. I remember that about that system. We laughed again and I went on my way.

Fast forward to Saturday. My family decided to do some school shopping and see what was left at the local Borders. It was getting to be late in the afternoon and hunger was starting to set in. As we drove to the Italian restaurant, a storm kicked up. I dropped my wife and kids at the door and ended up parking a considerable distance away from the door. I hopped out in the rain and hurried in. The only part of my body that the umbrella protected was my face and hair. Everything else was soaked.

By the time that we finished eating, I was still pretty damp. The storm had passed so we decided to hit another store.

While in the store I put my hand in my left front pocket. That's when I realized what had happened.

You see, I was going to need a dose of my antibiotic while we were out shopping. Rather than bringing along the prescription vial, I just shoved a capsule in my pocket.

What happens when the gelatin of a capsule gets wet? You know, like when it sits in a damp pocket for a couple hours.

That's right the gelatin dissolved to the point to where the contents of the capsule were now lining my left front pocket. I was half mad, half amused at what happened. Over the sixteen years of my career I have preached and preached and preached about not storing medications in humid environments. And look what happened to me, the pharmacist.

If only I had agreed to my counseling.

Saturday, August 6, 2011

Senna + bisacodyl + docusate + PEG =

I've kept this photo saved on my computer for a while, not sure when the appropriate time to post it would be.

Well a couple weeks ago, we had a couple incidents on our med/surg floor that made me think of this picture. We had people (on back-to-back days) produce BMs after 5+ days of constipation each. The hospitalist's words "it was all over the room".

Nursing and housekeeping earned their pay on those two days.

Have a great weekend.

Tuesday, August 2, 2011

Fellow pharmacist's lament

I don't think I can do this anymore.

I'm tired of the customer's word weighing more heavily than mine. Then, after they take the trouble to call in a complement on my behalf...

It's more or less disregarded or soon forgotten.

I'm tired of being asked to do more and more and more, and given practically no incentives whatsoever.

I'm tired of being talked down to by grocery personnel. I'm tired of being resented. I'm tired of pharmacy being mis-understood/appreciated.

I'm tired of being surrounded by incompetents and maniacs, then getting hammered whenever I happen to screw up something.

I'm tired of having to be a customer service kiss-ass to some of the worst scum and biggest jerks. And if they complain, I get rear-ended.

I'm tired of corporate breathing down our back telling us to increase flavoring, give more flu shots, take this training on your off day, et

I'm tired of catering to everyone else and then being treated like a drone in return.

I'm tired of getting lectured and scolded for petty things that aren't even my fault or that big of a deal

Where's the respect? Where's the appreciation? Where's the benefit of the doubt? Why are we never cut any slack?

I'm almost 40 and I hate my job. What the hell am I gonna do now?

Those are a series of tweets from a fellow pharmacist on Twitter several days ago. Sadly I can relate, as can many of you. In fact, I imagine that just about every chain pharmacist feels the same as this pharmacist.

I'm waiting for a member of management, somebody at the district manager-level, to grow a pair and stand up for their pharmacists. If you have such a DM, praise them. They are your voice.

Don't wait for the national organizations to speak up for you, it's not going to happen anytime soon. You invested the time and money to earn your degree. Don't sit back and let some corporate officer ruin YOUR profession.

Speak up.

Wednesday, July 27, 2011

Anti-meth PSA

Writer's block. So today I'll share a few photos to serve as a public service announcement in the battle against methamphetamine.

I'm not advocating meth with the above photo. It just allowed the Star Wars geek in me to include Chewbacca in a pharmacy blog.

This next one kinda reminds me of a certain actress who has some substance issues. Last name rhymes with Rohan (for the Lord of the Rings fan in me).

And the most compelling argument against meth:

I'm scared about this last one. I think my six year-old daughter might be on meth.

Wednesday, July 20, 2011

Oath of a Pharmacist

At this time, I vow to devote my professional life to the service of all humankind through the profession of pharmacy.

I will consider the welfare of humanity and relief of human suffering my primary concerns.

I will apply my knowledge, experience, and skills to the best of my ability to assure optimal drug therapy outcomes for the patients I serve.

I will keep abreast of developments and maintain professional competency in my profession of pharmacy.

I will maintain the highest principles of moral, ethical, and legal conduct.

I will embrace and advocate change in the profession of pharmacy that improves patient care.

I take these vows voluntarily with the full realization of the responsibility with which I am entrusted by the public.

I found a copy of the Oath of a Pharmacist that was provided to each member of my graduating class by the AACP while searching for something in my basement a few days ago. The ideas expressed in the oath are the ideal. Let's compare the ideas with reality in the community pharmacy.

I will consider the welfare of humanity and relief of human suffering my primary concerns. Not a 15 minute guarantee. Not playing insurance agent. Not dealing out gift cards. Pharmacists want to help those who are hurting and impact the health and well-being of the patients who come in to see us. Trying to do this while filling 300+ prescriptions per shift is difficult at best.

I will apply my knowledge, experience, and skills to the best of my ability to assure optimal drug therapy outcomes for the patients I serve. Um...yeah. With less than two minutes per prescription, "optimal drug therapy outcomes" means that the patient isn't going to die from the prescription. Community pharmacists are simply not given the time to do this. DUR. In retail/chain pharmacy? Other than glancing at a pop-up window for drug-drug interactions, what DUR is being performed?

I will keep abreast of developments and maintain professional competency in my profession of pharmacy. Community/retail/chain pharmacists are actually able to pull this point off. At least a majority are able too. Sometimes I wonder about the competency of the floater pharmacists who come through. And I've always been concerned about the competency of management. Seriously. But so has every other pharmacist.

I will maintain the highest principles of moral, ethical, and legal conduct. Pharmacists...yes. But somehow pharmacists are lumped in with pharmaceutical manufacturers. And the insurance companies. For some reason people think it's the pharmacist who decided to increase their Lipitor copay from $15 to $45. But we'll take the blame. And give you a $25 gift card for your trouble.

I will embrace and advocate change in the profession of pharmacy that improves patient care. Advocate change. Most pharmacists are afraid to speak their minds to management. Until more pharmacists speak up, all the changes that are implemented won't be for better patient care, but for better earnings reporting to Wall Street. But don't hang your hat on the changes that are being proposed by academia. You have to remember that the bills still need to be paid. Before rolling out major changes to how pharmacy is practiced, we need to make sure that we will be reimbursed for the changes. Too many times the profession has started doing things for free, with the hopes of getting reimbursed when it becomes mainstream. You know where we are now, right?

I take these vows voluntarily with the full realization of the responsibility with which I am entrusted by the public. Pharmacists are aware of the responsibility that we are entrusted with. Maybe some members of management need to spend a week behind the counter, shadowing pharmacists to see what responsibilities we have to the public rather than handing down additional tasks that benefit the corporate.

Tuesday, July 12, 2011

Chains...what are they good for?

I'm a huge fan of the social media. It gives me a chance to throw ideas out and see the response of others who are active in the social media. I try to share my thoughts at least once a week on my blog, but life gets hectic and sometimes I have trouble sitting down to put together a post.

As a result, I have become a huge fan of Twitter. I can share quick thoughts and get feedback almost instantaneously. Recently I made a comment about chain pharmacy ruining the profession of pharmacy. A fellow Tweep asked me to explain. I was going to send him an email, but then it struck me that the topic could be something I could use for a blog post, so here it is.

Let me start out by saying that chain pharmacy has put a lot of food on my table and made a lot of house payments for me. I have worked in the chain environment for the first sixteen years of my pharmacy career. I have learned a lot from these experiences. When I started, the chains weren't too bad to work for, but over the years I have witnessed the profession of pharmacy devolve into its current state.

What is now accepted as pharmacy practice in the chain pharmacy setting is a far cry from what it once was. Marketing ploys have changed the profession of pharmacy into simply a retail job. This post will focus on some of these ploys that have taken pharmacy to unprofessional place that it is today.

First up... insurance contracts. I can assure you that an independent pharmacist wasn't the first person to sign an AWP - 17% + $1.50 contract. It was the big boys. The ones who are able to withstand the lower reimbursement rates because they get larger discounts by buying in bulk. Smaller operations were forced to accept the low rates or risk being dropped from a PBM's network. Now the PBM's have developed multiple reimbursement formulas that capitalize on multiple reimbursement formulas. AWP, WAC, GEAP, FUL, and MAC may look like alphabet soup to you, but to the PBMS it's a means to guarantee that they will pay the least amount for a medication that they can. Some insurers have gone as far as to establish their own MAC lists. Good luck getting a copy of that list. In the take-it-or-leave-it world of PBM contracts, most pharmacists sign the contract without even reading the reimbursement rates. And we can thank the chains for starting us down that road.

Next on the list... gift cards and coupons. Pharmacy is a medical profession, not a marketing ploy. But rather than growing pharmacy business by offering superior medical care the chains decided to start bribing patients to come to their establishments. Transfer two prescriptions and get 25 bucks in gift cards became the norm. These days the chains use the gift cards to handle complaints from customers. That's right, I called them customers and not patients. Patients have relationships with their medical professionals. How many district managers have ever used the term patient counts? It's always customer counts. That's how they view the phamracy patrons.

Next up... 24 hour pharmacies. Other than emergency departments, what medical professionals are open 24/7? Let's expand the question to professionals in general. How many lawyers have 24/7 hours? Or accountants? Yet pharmacists are working in these conditions all over the country. And if you've been paying attention to the news, you'll see that there have been a number of pharmacy robberies lately. Should medical professionals be putting their lives at risk so that Henry can pick up his Vicodin at 4:00 AM?

Ever see on of these... drive-thru pharmacies? Some will argue that drive-thru pharmacies offer a convenient alternative to people who may have difficulty walking back to the pharmacy department. Ask a person in retail pharmacy who actually utilizes the drive-thru. Rather than helping a very small segment of the patient population, drive-thru windows have advanced the notion of fast-food pharmacy.

Speaking of which... 15 minutes guarantees on prescriptions? Thank you Rite Aid for that wonderful idea. While I have worked at pharmacies that have been able to have wait times of less than 15 minutes, it was never guaranteed. The guarantee puts an extra level of stress on the medical professionals who work in the pharmacy. Can you imagine your dentist promising root canals in 15 minutes or less? You would question how professional the service would be. Enough said.

These are just some examples of what the chains have done. There are many other things that the chains have promoted that have helped to devalue the profession of pharmacy. Feel free to share them with me.

Wednesday, July 6, 2011

Florida pharmacists and the PCMA

A few weeks ago I came across an article that talked about the state of Florida's employee prescription benefits. The jist of the story was that state employees and retirees were being forced into using the mail order option for certain medications. This isn't anything new. Employer groups force their enrollees into mail order all the time.

But the article quoted an organization that I had not heard of previously. The Pharmaceutical Care Management Association (PCMA).

The name of the organization sounds like it has the best interests of the patients in mind. I mean pharmaceutical care is in the name of the organization. But is that really the case. On June 16 and 17, the PCMA came out with guns blazing, attacking independent pharmacies for wanting to protect their profits instead of caring for the patients.

I don't see it that way.

Anybody who has worked in community pharmacy knows of the problems that occur when patients are forced to use mail order options. Hours are wasted every week in efforts to get a two-week supply of medication covered for patients whose mail-order prescriptions haven't arrived.

When community pharmacists are filling prescriptions for medications used for acute situations, we are dependent on the software at the insurance company to flag potential drug-drug interactions since the entire history is not available to the community pharmacist. The PCMA tries to assure us that their software catches all potential interactions and that complete insurance claims history is available to both the mail order and retail pharmacy to screen for interactions.

Did you catch that?

The PCMA says that the insurance claims history is available to both the mail order and retail pharmacy. I've never been provided with a patient's claims history in order to conduct a thorough DUR, but that's not the point.

I don't know about where you work, but in my area a lot of people bypass the mail order mandate and just pay cash for their maintenance medications. Over the last five years, there has been a huge uptick in this practice since four dollar prescriptions have rolled out.

The so-called safety check that the PCMA touts is actually being bypassed. Complete DUR evaluations are not being performed and patients are being put at risk. Pharmacists are not given an accurate picture of a patient's drug therapy.

The PCMA knows, as do community pharmacists, that the best pharmaceutical care is provided when a patient gets all of their prescriptions filled at one pharmacy. The PCMA is just afraid to admit it out of fear of losing money.

I applaud the pharmacists who have spoken out against the state of Florida and the PCMA. Your voice is being heard. Don't give up the fight.

Wednesday, June 29, 2011

Curbing the narcotic problem

By now you have probably heard about the Father's Day incident on Long Island that left two pharmacy employees and two customers dead, victims of an armed robbery. Apparently the gunman was trying to obtain controlled substances for his wife.

If you run over to Google and search for "pharmacy" in the news, you'll get a steady stream of stories about robberies and thefts at the pharmacy. A few weeks ago, up until the Long Island incident, the pharmacy stories revolved around the murder conviction of an Oklahoma pharmacist who emptied his gun into a man who had attempted to rob his pharmacy.

Around the same time there were stories floating around about a Michigan pharmacist who fought back against some robbers, unloading his weapon during a middle-of-the-night robbery. He was subsequently terminated for his actions.

These aren't the headlines we want to see for the profession of pharmacy. But the reality that we face today is that there are many addicts in this county, and they are becoming bolder in their attempts to obtain controlled substances. Pharmacies are the places who the controlled substances are, therefore pharmacies are the targets.

What are the reactions to these events? New York Senator Chuck Schumer has come out with a plan to require prescribers to undergo additional training before being able to prescribe narcotics like Vicodin and Percocet. His plan also calls for increased penalties for people who rob pharmacies.

Prior to the Long Island incident, the APhA (in Pharmacy Today) was reporting on the White House's plan to curb prescription drug abuse. For the last several months we've heard about the opioid REMS (Risk Evaluation and Mitigation Strategies) requirements that have been in the works.

The opioid REMS program calls for voluntary physician training when it comes to prescribing opiates (although there is talk of linking training to DEA registration). It also calls for pharmacists to distribute a MedGuide along with each prescription for the affected products.

Other projects/programs that are being used to help curb the abuse of narcotics include prescription drug monitoring programs (the one in my state is not real-time, it has a two-week lag), prescription drug take-back days, and Cephalon's when good medicines become bad drugs program.

As a practicing pharmacist, these programs do absolutely nothing to stop the abuse of narcotics. Anybody who works in community pharmacy knows how people will do or say anything to get their drugs. I honestly don't think handing a patient an extra sheet of paper telling them how the opiates might be bad for them will really affect their efforts to obtain morphine. A coloring book for kids isn't going to keep an addicted mom from deceiving a clinic physician in an attempt to score some hydrocodone. These programs may make non-practicing pharmacists feel good about doing something to curb the narcotic problem, but do they really do anything? In my opinion, the answer is no.

So what is the solution?

There isn't one. But that doesn't mean that steps can't be taken to attempt to slow things down. The solution isn't one that falls strictly to the medical and pharmacy professions. It includes law-enforcement and the federal government. I won't go into the details of what the cops and feds should do, let's just say that they needs to be involved even more than they are.

For those of us in the medical professions, we need to have real-time information provided to us, as well as having security measures in place for the protection of the employees at the pharmacy.

When a patient visits a prescriber, there needs to be a means to relay to the pharmacy what was actually prescribed. We've all had somebody present a prescription for Percocet or Vicodin from the ER late on a Saturday. In your gut you know that there was a second prescription issued, but somehow it was lost between the ER and the pharmacy counter.

As much as I hate the thought of a centralized database, I propose a centralized database that records everything that has been prescribed as well as what has actually been filled for a patient. The process is simple... any time that you visit a prescriber you must present your identification card. The prescriber swipes the card thru a reader and is able to see what meds you have been prescribed, who prescribed them, what you actually had filled, and where you had it filled.

Before releasing you with your prescription, the prescriber would record what medications they were prescribing and upload it to the database. When the patient visits the pharmacy, they would hand over both their prescriptions and the identification card. The pharmacist would be able to see what the patient should be having filled and compare it to what is actually being filled. If you don't present all of the scripts or only request the narcotics, the pharmacist records it in the database. That way future prescribers and pharmacists have a better picture of the behaviors that a particular patient has used. Ideally diagnosis codes would be included as well, so all of the health care system would know what the patient's chief complaints have been.

I would like to see the diagnosis code be a required part of the prescription, similar to Medicare B testing supplies. When a prescription is filled, the DEA number, NDC number, quantity, and diagnosis code would be transmitted to the DEA. That way the DEA could track (in real time) which prescribers are ordering which medications for particular diagnoses. A family practice physician who suddenly starts prescribing 720 oxycodone 15s, 120 Percocets, and 60 Oxycontin 80s to every third patient for chronic lower back pain could be stopped before they draw every addict in a fifty mile radius to their practice.

Those steps may help to lessen the chances of creating addicts, but the pharmacies need to be protected from the current addicts. This is where it gets a bit dicey. Pharmacists wear it as a badge of honor that we are the most accessible health care provider. But I don't think any of us want to see our accessibility lead to the death or injury of another pharmacy worker.

I have absolutely no problem with the thought of working behind bulletproof glass. Heck, I'd work out of a bank vault with drawer (similar to a drive-thru set-up) if it means keeping my staff safe. Time-delay safes for narcotics...absolutely. No narcs after 6 PM...sounds good. I've had armed guards escort me from the pharmacy lab to the front door before, then watch me from the door as I've crossed the parking lot to get to my car. If it keeps me safe, I'm for it.

Anyhow, it's getting late for me. I thought I'd share some of my thoughts on the narcotic problem that is affecting our profession as well as offer up some solutions. What are your thoughts?

Tuesday, June 28, 2011

Test post

This is a test of the feature that allows me to publish posts by simply sending an email to a specific address. This could come in handy if I have the desire to develop and type an entire entry from my phone.

There is no content related to the profession of pharmacy in this post. I am working on a few ideas and should have an actual, substantive post in the near future.

As an aside, I have been busy getting ready for my change from community pharmacy to hospital pharmacy. Only six more retail shifts remain after today. I am excited for the move, especially since the main medical practice group at the hospital wants me to get an anticoagulation clinic up and running in the near future.

This concludes today's test post.
Eric Durbin

Wednesday, June 22, 2011

Thoughts on prescription volume and liability for errors

Imagine if you will the following scenario... district manager calls the pharmacy to speak with the pharmacy manager. A short conversation ensues where the pharmacy manager is speaking in a hushed voice and starts to look frustrated. After the call, the pharmacy manager pulls the other pharmacist(s) aside and tells them that corporate has determined that the pharmacy volume isn't high enough to support the pharmacist staffing and, as a result, pharmacist hours are going to be cut.

Imagine that at the current staffing levels, each pharmacist is verifying an average of twenty prescriptions per hour. That is on top of counseling patients, making OTC recommendations, talking to physicians and nurses on the phone, resolving third-party issues, evaluating DURs, etc... Three minutes per prescription without those distractions isn't that much time.

Imagine that the new staffing algorithm calls for pharmacists to verify (on average) twenty-five prescriptions per hour. Two minutes, twenty-four seconds per prescription. Not counting the distractions. If I look up the word disaster in the dictionary, I might see this as an example.

In the sixteen years that I have been a pharmacist, the profession has devolved from what was once a medical profession that took care of patients to a fast-food operation that wants to see how many customers they can get thru the doors. Pharmacists who work in this environment are afraid to speak up out of fear of losing their jobs.

What has led our profession to this? Several factors come into play.

Corporate ownership of pharmacies is a biggie. When the people who make decisions about the operations of the pharmacy don't actually work in a pharmacy, there is a major disconnect. It's even worse when the managers making these decisions aren't even pharmacists. I've had managers who have been pharmacists and managers who aren't pharmacists. At least the pharmacists have some idea of the realities of the profession, even if they have sold out as they have moved up the corporate ladder.

Declining third-party reimbursements. The argument is that declining margins mean that more scripts must be filled to make the same profits as before. There is a simple solution... stop signing contracts that don't reimburse at a respectable level. Everybody seems to be afraid of turning away people if we don't accept their plan. Hoping to make up for the horrible reimbursements on the prescriptions by selling a extra tube of toothpaste as an impulse buy. I was able to obtain a copy of a third-party contract at my previous employer. The terms for generic medications were AWP- 25% + 1.75 for 30 day supplies. AWP- 50% + 0.00 on 90 day prescriptions. And the employer was pushing us to get the people on 90 day prescriptions. ???

Four dollar/free prescriptions. Apparently the corporates offering these programs aren't afraid of telling you exactly how much they value your training and expertise. Nuff said.

Surplus of pharmacists. Remember 15 years ago when there was a pharmacist shortage? Then all the new pharmacy schools opened up. And now the job market is flooded. Remember how companies used to treat pharmacists well in order to keep them? Now pharmacists willingly accept being treated as highly-trained monkeys in order to remain employed.

Pharmacists need to stop being so timid when addressing issues with the members of management who are making the decisions that are destroying the profession. It's not their license and livelihood that is on the line if a mistake is made. It's yours. If you won't speak up for yourself, who will?

We need to remember that we are medical professionals first and foremost. We are liable for any and all errors that may occur in the pharmacy. Some pharmacists are lulled into a false security when employers say that they will carry a liability policy to cover the pharmacists. The policy that stipulates that all policies and procedures must be followed exactly or else the coverage is not valid. I'm guessing that it takes longer than two minutes, twenty-four seconds to follow the policies and procedures on each prescription.

This is just a thought on the subject, but the next time there is a major error that occurs due to a pharmacist being required to fill too many prescriptions per hour/shift, I'd like to see some other defendants in the courtroom. Instead of just the pharmacist and maybe the corporate being named in a lawsuit, I'd like to see the district manager, regional manager, and everyone up the corporate ladder all the way to the CEO being named in the case. Maybe if the members of management who make these staffing decisions are held just as liable for errors as the pharmacists in the field, we may see some changes.

Wednesday, June 15, 2011

Here is more from my conversation with a fellow frustrated pharmacist. I find some of his insights very interesting. Again, what are your thoughts? Please share them here for everybody's benefit. I appreciate the emails, but more people see your thoughts when they are in the comments and not my email inbox.

I just read part of your note to Jim. Anybody that says they are an expert in MTM is not being entirely straightforward, in my opinion. If there were such a person and he/she knew how to do it and make it meaningfully profitable, they should be shot if they keep that information to themselves. People may be experts in "MTM" if they have charts available but they are still not managers of drug therapy in the sense Hepler and Strand meant it. We are not given and don't have the right to be responsible to the patient for drug therapy. That still rests with the doctor--we would need an OK from each MD and that's not what Hepler and Strand meant. But what they meant is extremely unlikely to ever occur (my opinion). The Ashville Project was and is such an artificial situation, I'm not surprised they can't give you an exact amount the pharmacists were paid. It was something that evolved over time. At first, the pharmacists spent varying amounts of time and their documentation was very sloppy as to what they actually did. They were also assisted by a diabetes nurse educator who did alot of what we would hope to bill as MTM. They also had a leading community physician running as a front man for them to help get physicians reluctant acceptance and several hospitals, as I recall, were also involved. I'm relying on memory of articles I read about 7 or 8 years ago that I have since thrown out (along with my hope of MTM ever being a working model). I don't know that academia and APhA are actually keeping anything from you so much as they probably really don't have precise figures and the services/types, records, etc varied over the years. Pfizer is now a major sponsor of Ashville and I wouldn't believe anything Pfizer had input on anyway. They back the PBM's and we know what the PBM's think of retail pharmacy. We are fighting against billions of dollars and some of those dollars have been used to compromise APhA. In my opinion, APhA tries to sound like pharmacists is who they represent, but the real money comes from large pharmaceutical corps. that they must feel they can't afford to piss off. Look at the response Tom M. (APhA exec. VP) gave to David Stanley's editorial, "You Talkin' For Me?" in Drug Topics. He barely hid his hostility. He brushed aside David's points and essentially accused him of not knowing how to use technology or technicians. He referred to him as "Stanley" every time he mention David's name except the first time when he called him "David Stanley." I got no sense that he felt he was talking to a colleague but to someone that pissed him off by telling the truth.

Friday, June 10, 2011

Frustrated with pharmacy

There are times when I get frustrated with my profession, as I'm sure you do too. This blog has enabled me to make connections with pharmacists from all over the world. A few months ago I had an email conversation with a fellow pharmacist who is frustrated. I was actually looking into other career options at that time.

The following is copied/pasted from one of the emails. I have permission to share this from the other pharmacist.

What are your thoughts? Are you as frustrated with your profession as this pharmacist is?

My quest is to get out of pharmacy too. I went back to graduate school at age 53 and got a Masters in Mental Health Counseling with an AODA concentration. I graduated 3 years ago and have had to stay in pharmacy to pay the bills for graduate school. My wife is about to start a job as a nurse and if I could find a job at $60,000 per year I'd be gone tomorrow. I've done AODA counseling as part of our graduate training. The satisfaction I get from working with alcoholics and addicts is way beyond any satisfaction I have gotten from pharmacy. Plus, we actually use much of what we were taught in school. What a novel idea. With the economic downturn, finding an AODA job in my area (NE Wisconsin) is tight but I keep looking and hoping. Good luck in your quest. Do you know why they call it the "Asheville Project"? OK, neither do I but one of the reasons has to be because it never ever came close to reaching the controls necessary to qualify it as a study. That pharmacy would trumpet it as "evidence" of anything is further proof of how little proof MTM has as a viable model. In graduate school, I had to take a stats course and several research courses. "Asheville" as a study would have little internal or external validity because there were so many variables that were not controlled (confounders) and its widespread applicability (generalizability or external validity) to other practice types is extremely low. To answer your question as to where the MTM model came from, it was a paper Hepler and Strand wrote in approx 1990 about pharmaceutical care and its application, MTM. Only someone in pharmacy would consider it even a remotely possible practice model. Unfortunately, all pharmacy schools subsequently did. Now we have Doctors taking orders from Med Techs--they had to come up with a degree appropriate to all the new responsibilites pharmacists would have--hence, the 6 yr. PharmD. If I was a PharmD, I'd be pissed.

Tuesday, June 7, 2011

Prescriptions per hour

I recently posted a poll that asked the following question:

How many prescriptions can a pharmacist fill safely per hour (including counseling)?

The results did not surprise me:
  • 0-10 (10%)
  • 11-15 (44%)
  • 16-20 (30%)
  • 21 or more (16%)
The majority felt that 11-15 scripts per hour was the safe level. At that rate, you have 4 to 6 minutes per prescription to verify the accuracy of the prescription label, check the patient profile for duplications/interactions, contact prescribers if any issues arise, call the insurer if needed, verify that the contents of the prescription vial are accurate, and counsel the patient on their medication.

Not included in this 4 to 6 minute span are the interruptions that a pharmacist must deal with. A patient asking for an OTC recommendation. Phone-in prescription from a prescriber's office. Phone ringing from a patient phoning in refills (I actually think that there is a rule somewhere that requires a pharmacy to have two more phone lines than people working in the pharmacy).

But back to what we actually do. We rely on the DUR software to help us check for interactions, but a recent study from the University of Arizona found that the software systems are flawed (link here). That means that we, as pharmacists, should dig through a patient's profile each and every time that we fill a prescription to check for interactions. That takes time.

Another part of the prescription process that take time is counseling. From my experience and observations, pharmacists fail at this horribly. I watch how pharmacists counsel patients on their prescriptions. 95% of the time "counseling" is simply the pharmacist reading the label to the patient. OBRA '90 gave us specific points that we are to cover when we counsel the patients.

OBRA ’90 Counseling Points:
  • Name of drug.
  • Intended use and expected action.
  • Route, dosage form, dosage, and administration schedule.
  • Common side effects that may be encountered,including their avoidance and action required if they occur.
  • Techniques for self-monitoring of drug therapy.
  • Proper storage instructions for the medication.
  • Potential drug-drug or drug-food interactions or other therapeutic contraindications.
  • Prescription refill information.
  • Action to be taken in the event of a missed dose. (source)
To inform a patient on all of these points, time is required. Two or three minutes, per prescription, is what I feel is adequate to ensure that the patient understands what I am saying. Then you need to allow time for questions from the patient.

* * * * *

So I found it amusing recently when upper management decided to change the guidelines for the number of prescriptions a pharmacist should fill on an hourly basis. I'll just say that, prior to the change, we were at the higher end of the volume spectrum of the poll. The new guidelines call for an increase of 25 percent.

I contacted my state board of pharmacy, whose mission statement states that it is to the public interest to pursue optimal standards of practice through...legislation, licensing and enforcement to see what their take on my employer's changing guidelines were. The response from my pharmacy board was that no prescription volume limits have been or are being considered. Apparently my pharmacy board believes that a maximum time of two minutes, 24 seconds per prescription is the optimal standard of practice.

Eric Cropp lost his pharmacist license permanently due to a dispensing error. He was in a situation where there was too much work to be done with inadequate staffing. The little girl who was undergoing her last chemo treatment ended up dead from the error. So when he speaks about the rapid pace of pharmacy and the potential for error, I'm paying attention. He was quoted in a recent internet article as saying "We want to stress the fact that everybody's got to slow down and treat each patient like they're a member of your family...Healthcare is so fast and crazy sometimes we start to miss the fact that we're taking care of a human being, not running an assembly line."

If only the management of the pharmacy chains would think the same way.