CVS in hot water…again!


Seems good old CVS has been at it again, caught red-handed selling those rotten expired drugs to grandma and grandpa. Why those greedy little rascals! Well…
The story is a little more complicated than that. I have no great love for CVS (or Rite Aid or Walgreens or any of those boxy corner chain drugstores), and this is one of the reasons why.
Pharmacy managers have a duty to check for expired products. And I haven’t met one manager in my life (well, maybe one) who did not take their job seriously enough to check for expired medicines.
So why isn’t it being done? Let me think for a second…how many drugs are stocked in a typical pharmacy? One bay in a pharmacy can easily contain a thousand drugs and there can be four or five bays. So, understaffed (and every pharmacy I’ve ever seen has been understaffed) and filling a prescription every minute to two minutes, how can anyone expect expired products to be up to date? Well, guess what. They’re not. Not likely to be for the foreseeable future either.
All CVS and the others have to do is give pharmacists enough staff to do their jobs. Period. End of problem. But I tend to think that CVS would rather risk the penalties than have to pay employer salaries and benefits. It’s really about the bottom line; don’t let them kid you into thinking they are looking out for the public’s benefit. They’re not. Never have; never will.

(Sung to “I Dreamed a Dream” from Les Miserable):

There was a time when men were kind
And they all forgave their debtors
And insurance was not needed
When all was done by shaking hands, not needing to be signed…
All transactions done in cash,
Town meetings civil and seated.
There was a time…then it all...was trashed.

I dreamed a drug was well-tested
And offered something new
I dreamed it was low-cost
And not just another me-too.

I dreamed the dream I had when young
When costs were paid in dollar bills;
No forms filled out, no effigies hung;
No need for insurance and other frills.

But the lobbyists come at night.
With their voices soft as moleskin.
The PACs and pol’s keep out of sight
They’ve crossed out Lipitor and Ceftin.

When I was young and unafraid,
I could read a doctor’s writing without specs.
E-scripts simply don’t meet the grade--
Is it Prilosec that’s meant or Phisohex?

I dreamed that copays were all the same
I felt as if in a wonderful trance.
I dreamed the sick could not go broke,
That health care was as it was in France.

He filled my summer with endless joy.
He saw the poor had medication.
MTM was everywhere
Even time for vaccinations.

And still I dream he’ll sign a bill.
A bill for us and congressmen.
Where we can all get our fill
Of tests and beds and pills.

I had a dream that life’s worth living.
That lick-and-stick would be a passing thing.
I’d be up above it all and counseling—
Now life has killed the dream, I dreamed.

Patents and the new biologics

Time magazine (Nov.2) has a recent article of note, "You don't know him but he may be the biggest winner in health-care reform. So who loses?" In it, a particular paragraph caught my eye:

    The Federal Trade Commission (FTC), though, argued in June that giving biologics makers any period of exclusivity at all could actually stifle innovation. Biologics are so much more complex and expensive to produce than traditional drugs that the barriers to would-be "biosimilar" competitors are already high, the FTC said. Giving biologics further protection—particularly the 12 years of exclusivity that the industry wants—would merely encourage firms to tinker with what they have rather than drive them toward "new inventions to address unmet medical needs."

The authors, Karen Tumulty and Michael Scherer, are speaking to the controversy re patent exclusivity on expensive biologics, which will soon comprise a hefty share of the pharmaceutical industry's product base as well as their future profits.

The principle sentence here would be the first, that the industry would be driven to produce "me-too" biologics instead of bringing out truly innovative drugs.    What happens now in the pharmaceutical industry when a patent drug expires is that the drug maker produces a similar drug, the active metabolite for example (Nexium from Prilosec), or another drug form, controlled release say (Ambient CR from Ambien). Instead of trying to market a new, unique drug for diabetes or blood pressure, the drug companies instead follow the less expensive pathway of producing drugs that offer no significant difference in efficacy than those already on the market.

If, however, these companies could not count on the easy play of "me-too" then the economics of medicine would start to pressure those corporations into a more risky territory, giving the green light to more R & D in areas that desperately need true innovation.

The medicines that are being sampled in doctor's offices now are merely another ACE inhibitor, another beta-blocker, another sulfonylurea, another this and another that. Oh, it might last longer, sure. Big deal. It also costs a lot more, with no or little increase in effectiveness. That is one reason behind the big push to get sales reps out of physician offices. The newer agents being pushed are often just expensive alternatives that are given out free at the start but greatly increase the over-all burden to health-care as a whole down the line.

Of course, given the huge influence that the industry has on congressmen/women there is no hope for change. What a waste.

In the olden days if a Mafioso ratted on somebody he'd get thrown off a bridge or tossed off a rowboat wearing cement shoes. Nowadays nobody's ratting on nobody. And why's that? Because the new mafia has made it darn near impossible to rat anybody out, just because it's all so stinking complicated that hardly anybody knows what's really going on.

But the end game is still the same: kill any bugger that gets in your way or costs you money.

When somebody gets killed every half hour in this country you'd think it might just get noticed. Nah. First you'd have to know the links, how it all fits together. And with a body on the floor who's going to notice the dozen different things that caused it to happen in the first place? Nobody, that's who.

Here, I'll give you an example. Say Johnny Walnuts starts to notice his crew isn't taking in nearly as much as it did last year. So he ups his premiums, say. Things start to look better, but not as much as Joe, aka "Prior Auth" Lucchese, the Godfather to his cronies, expects to get from his pals. So he thinks, Maybe double the copays. Yeah, that's the ticket. Oh, and while we're at it we're going to put limits on cancer drugs. And biological. Heck, anything that costs a lot. People will assume they're still covered, but they won't be really. If they get the Big C, Joe says, then we're collecting the benefits without paying the dividends, see? Beautiful!

Everybody saw the beauty of it: big money flowing in, very little paying out. And with every little bit of small print added the complicated became even more complicated, which just meant fewer and fewer people would be able to connect the dots. The Barzini family at Aetna, the Tattaglias in Humana, the Corleones of BC/BS, and the smaller families that feed off the crumbs left them, they all began to multiply the separate plans within each family, until there was over ten thousand different "insurances" offered over the entire country. Each had the same complicated structures—which the families changed month to month without even notifying anyone! The plan worked perfectly, until some smart accountants started noticing all the money we'd been spending compared to other countries. They thought that maybe the country was getting ripped off. Of course they were right.

When it turns out that some poor schmuck's cancer isn't covered the guy can't afford the treatments. First, he goes bankrupt, then he dies. The girl waiting for the new liver never gets it approved. Sure the girl's mom takes "The Company" to trial but by then it's way too late. And the company's lawyers still get paid! Oh the plan is so perfect the old time Mafia must be weeping over their beers. They thought they had it good, knocking on the doors of a strip joint and speak easy, "asking" for insurance money just in case somebody might happen to want to burn down their joint. The real money, they learned, was in the real, actual insurance business. The new mafia is making mince meat out of the old, all the time acting like they're all hot shot businessmen. They even have their own political party, the Republicans, to try and complicate things even further, blaming government for the mess. Can you imagine! That'd be like the Gambinos blaming the FBI for all the mafia mess. The weird thing is that it's working. It's like somebody once said, killing is their business, and business is good.

I Robot (part deux)

If the pharmacy industry can finally solve the riddle of how to serve a patient's need for personal consultation (now vastly underserved) while demanding more and more of the pharmacist's time, then we will enter the next stage of medication management.

As I wrote earlier, robot dispensing of medications holds great promise to free up the pharmacist to actually do what he/she is trained for: medication management (known in the biz as MTM, short for Medication Therapy Management ), inoculations, and training patients to better manage their disease states.

It is amazing that students spend six years in training for disease and medication management but when introduced to the business world none of what the newly graduated can offer is actually used.

Can pharmacists reduce the costs of health care by catching provider errors? Yes.

Can pharmacists reduce hospitalizations, and emergency room use through Medication Therapy Management, increasing adherence to medication use? Yes, again.

Could pharmacists save doctors time (and money) by being allowed to make therapeutic substitution when the insurance denies certain claims? Of course.

These are all proven. MTM is even now included within Medicare reimbursement to providers. There is really only one missing piece: Time.

No one has the time to actually talk to patients. No one has the time to give vaccinations. The only thing I have time for is to dispense one prescription a minute. Barely. Even with robot use, as in Rite Aid and Walgreens, time is still a precious commodity. There are too many silly regulations by state boards that waste a pharmacist's time (make sure that you sign every single line of that 222 form! And date that invoice that is already dated. And put that address on the line that the doctor was supposed to put in even though it's already in the computer record.)

The pharmacy of the future holds great promise. I see technicians doing pretty much what pharmacists do now, possibly even including the verification stage of prescription processing. Technicians aren't going away, even in a robot driven world. They will always be needed. And pharmacists too will be needed, just differently, to be used instead as a real member of the health-care team, instead of as an ancillary player. We simply have too much to offer to be ignored for much longer.

I Robot?

I've been wondering lately if retail pharmacy is dead or at least ready for some major triage.

It's not that the local pharmacy is going to go the way of the dinosaur. Pharmacies will never disappear. But I do think they are going to evolve into a different "animal" than what we see on the corner now. I say that because of the different circumstances faced by the retail druggist than existed even just five years ago.

In January of 2006 millions of elderly Americans began prescription coverage with Medicare Part D. This was not only a boon for seniors; it brought increased foot traffic into drug stores. The volume of prescriptions filled sky-rocketed. Then a couple of years later Wal*Mart brought its own brand of insurance reform by instituting their list of $4 medications. In an industry not known for creativity this was an earthquake high on the Richter scale of business practices. It brought price point back to prescription drugs, competition where none had existed for years. "Me-too'ism" crept in and soon Target and Rite Aid and CVS and everybody else soon had some version to compete with Wal*Mart. More foot traffic. More volume. More prescriptions than could be filled quickly and safely.

Back before the days of Medicare Part D we routinely told our customers that we could have their prescriptions filled for them in under fifteen or even ten minutes. Now we doubt very much if we can fill anything in much less than forty-five minutes. We may say "a half hour" but we really mean "we're going to hope for less than an hour unless we get some insurance problems which really is a given anyway."

Can we keep traveling on this road? As baby boomers age the numbers are going to go up astronomically. Things are going to have to change. Something has got to give.

Robots might be introduced. Rite Aid first got on board with robots back in the late '90's, but I see all drug stores eventually filling scripts with robots within the next ten years. Or five. This is one of the things retail stores must learn from mail order firms. You simply need a fast, efficient, and safe way to fill more than one prescription a minute and robots are the only way to do that. Although the public will balk at first they will eventually see that getting their prescriptions fast will be a nice trade-off to an unfamiliar system. And whether they know it or not the millions of people already receiving their medicines from a mail order company get their scripts processed by robots.

So the next time you wait an hour or two you might want to reconsider your aversion to mechanized pharmacy. Science fiction isn't just for trips to Mars. It might be as close as your corner drug store.

A trip to the McDrug store

When did a pharmacy become a part of the fast-food nation? You walk into a pharmacy with your prescription in hand, present it to the technician or pharmacist, and start to walk away, confident that in a few minutes you will have your medicine and begin your life anew.

When did that happen? I started in this business in 1983. At that time I remember this same expectation of quick, efficient dispensing, though I also remember that a busy pharmacy back then did about 100 prescriptions a day. We were still typing labels, though a few envelope-stretching chains and independents did have computers. So if we did ten Rx's an hour that was a busy. That works out to be one Rx every 6 minutes. Nowadays we do one Rx every minute or two. (That doesn't mean you get your prescription in two minutes; it's more likely to be an hour as the volume has sky-rocketed.)

But back in the Jurassic period of pharmacy, independents used to fill prescriptions in a back room, beyond the view of customers (we used to call them patients). This actually has a lot to say for it, as privacy worries are supposedly at the forefront of everyone's concerns. These were the days when a lot of compounding happened, capsules and tablets as well as creams, ointments, suspensions, elixirs, suppositories, would be made in a lab. Labels would be typed. It took a long time to make a prescription. I doubt if anyone left off a script and just stood there tapping their fingers.

Yet now I have to listen to the constant complaint: "How long's this gonna take?" "Forty-five minutes? All you have to do is put pills in a bottle!"

It's just like going into McDonalds or Burger King, isn't it? Place your order and take two steps to your right, wait a few minutes while some technician pours pills into a bottle, and hand over your credit card. Would you like to super-size that? How about a nice stool-softener with your morphine—we have a special today!

Ideas for reform

 

Since everyone else and their pet dog gets to sound off on what is the best plan to overhaul the United States healthcare system, I thought I'd put forth a few of my own.

(Note: anyone who has been following this blog knows my reasons for advocating a single-payer system, so the following remarks are meant to be as an alternate to that most desired of solutions.)

• Lacking any real reform, which indeed seems now to be the resultant predicament we find ourselves in, we could save millions just by having one uniform billing form, and one uniform insurance card. I have seen insurance cards without any ID number, group number, processor number, or even a logo to let us know whom to bill. Honest.
  
• Give pharmacists the power of therapeutic substitution. If your insurance wants you on Prilosec OTC instead of Aciphex I could switch you to that drug without having to fax or call the office and wait the three days to hear back from them. They're only going to say switch it anyway.
  
• Advocate the use of free discount cards. We switched a patient taking generic Topamax to the generic saving quite a lot, but then we tried on a lark to send the claim to a free discount program. The price went from about $240 to $28! We use it a lot on the phentermine drugs which are never covered on insurance, causing the price to go from $30 to $12.
  
• Reimburse pharmacists to review patient medication profiles with the physician. I could save people—and insurance companies!—thousands, maybe millions, if I could afford to go over profiles. But I now do not have the time and no one can afford to not fill prescriptions in place of examining profiles. This would also probably prevent many unnecessary hospital visits due to adverse effects and interactions.
  
• Set up a regional or state-wide pharmacy ad-hoc committee every couple of years to go over ideas to send to government boards and insurance oversight committees. Pharmacists have a lot of great ideas for saving money.
  

Take away Sen. Chuck Grassley's insurance. See, if he didn't have insurance like the 50 million other Americans you'd have real reform, saving the country, oh, about a trillion dollars a year. Probably the best idea I've ever come up with.