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Monday, March 31, 2008

Your name is...

Customer: It's right there on the prescription: John Doe.
Pharmacist: Sorry, couldn't read it.
Customer: You can't read the prescription?
Pharmacist: It's pretty bad handwriting. I can make out the drug, though. How are you supposed to take this? What's it for?
Customer: You don't know what the drug is for? How long you been at this?
Pharmacist (now getting testy): 25 years. Drugs are used for a lot of different reasons. This one for instance. Prednisone. Used for inflammation, asthma, lupus, MS, and about a dozen others. It's also taken in different ways, and if I could read the handwriting I might be able to tell you how you are supposed to take it. Did the doctor--Oh, nurse--tell you how it's taken?
Customer: Yeah. Three the first three days, then two then one. Something like that. These doc's and their bad handwriting. They make you take a class in bad handwriting, right? [laughs]
Pharmacist: No. And I don't think it's funny anymore. Some say that about 100,000 die each year because of bad handwriting. Did you know that?
Customer: Huh.
Pharmacist: Listen, when you leave the office, look at the script before you leave. If you can't read it, ask for it to be re-written. It's your health care, right?
[An analysis by the Institute of Medicine’s Committee on Quality of healthcare [sic] America, a unit of the U.S. National Academy of Sciences, concluded that medical errors, including prescription errors caused by poor handwriting, might be partly or wholly responsible for as many as 98,000 deaths per year (L.T. Kohn et al., To Err Is Human: Building a Safer Health System, 1999).
Personal Note: The above is a fictional conversation, but I've had similar conversations with patients many times. It is no laughing matter. If you have a doctor who wont take an extra ten seconds to make the Rx legible, then either get a different doctor, or just ask him/her why they insist on putting you at risk? Some practitioners are simply obstinate and I would conclude uncaring. Case in point: A practitioner (PA I think) in Rutland Vermont who specializes in treating kids cannot write a legible Rx. The office even went so far as to make pre-printed forms. But even when using these the PA still has to put number of doses, or refills, or dosings, and these end up as unreadable. Amazing. I've let her know many times that this is dangerous for the kids, but is there any change? Nope. When I've called sometimes I get a little chuckle from the nurse who answers. I doubt there would be much chuckling when some kid dies and their practice is sued.

Saturday, March 29, 2008

All in a muddle...
is what we are. I am surprised at how little we learn day to day, at least about how to work and live more efficiently. We complain about having no time, yet we waste it like a drunk's profanity.

Case in point: How many times will a customer come to my register at the pharmacy, plop down a dozen or two items and then wait impatiently while I go through the motions of ringing them out. Some tap their toes, some their fingers. You can almost hear the most impatient of them say under their breath, come on, come on, I gots to be somewhere!

But do they bother to take the hangers off the soft lines (that's department store-ese for clothing) or put the UPC bars where I can scan them? Uh, that would be a no. Do they put the items where I can reach them? No again.

I might tell them that that might speed things up but I might as well be talking to my big toe, as one of my tech's likes to say.

Another, particularly vexing example: After waiting for fifteen, twenty minutes for their prescription--after having all their personal data loaded into the profile ("Any insurance? No?")--after waiting in line to pay, the following dialogue is customarily heard:
Customer: How much my prescription?
Pharmacist/Tech: That'll be $65.98.
Customer: Whoa! Ouch. Good thing I got insurance.
Pharmacist: What?
Customer: I said it's a good thing I got insurance.
Pharmacist: Oh, you mean an HSA? [Health Savings Accounts: you pay for these with a debit or check on an existing account meant for medical expenses]
Customer: Huh?
Pharmacist: Never mind. That'll be $65.98.
Customer: No--I got insurance. Should be 20 bucks.
Pharmacist: Do you have a card?
Customer: Sure. [proceeds to give us a card which could have saved us--and him--twenty minutes of aggravation] I wanted to see how much it was without. Wow.
Pharmacist: Wow. And thank you for the card. Thank you so very much. It's very helpful to have the card. Makes everything so much easier. For everyone. Now take a seat and we'll be with you in...twenty more minutes. Or so.
Customer: Twenty minutes? I've already waited twenty minutes. What takes so long? Don't you just run the card through and slap a label on it? [expletive deleted]
Ahh, people. We love you. Yes. Really. We do.

Wednesday, March 26, 2008

Slap a label on it...
is all I have to do, right? After all the guy was in a hurry. And he was from Manchester, snob capital of Vermont. "Can't you just do it right now? I can't run back here."

My technician explained (way too politely, to my way of thinking), that we were shorthanded, due to the flu going around, and that there were (gasp!) other people ahead of him.

Well where were they? he wondered. I wanted to tell him that not everyone plants himself down at the drop-off window like some potted shrubbery. "They're off shopping," is all I could come up with.

Later, after the guy took his prescription back, my technician said she wanted to "slap a label" on a box of ex-lax and give him that. After all, what's accuracy got to do with it when a guy's in a hurry.
Pisses me off....
when you try and save somebody a lot of money and they insist on wasting it. Case in point: A young woman comes in the the pharmacy wanting to fill her prescription for an antibiotic. How much is it? she asks. So we punch the little keys and tell her. $55.98 for the brand and $22.46 for the generic. I usually don't even tell the brand price as nobody buys them--heck, hardly anyone pays cash anymore so the insurance company gets to pick whether it is brand or generic and they rarely pick generic except when some special contract price has been negotiated--but this time I say both prices. She says she wants the brand. Huh? I say to myself. Do I even have the brand in stock? I check and we for some unknown reason actually stock it.

Well, what do you do? Just give her the stuff, I guess. If a customer wants to waste her money, then who am I to disagree. Except more than that is going on here. There is a trust issue exposed. I am trying to save her money, so I say that the generic is really the identical drug. (I like to use the word identical as it more strongly conveys the sense of being indistinguishable, of being equal to, than just saying something like "it's the same thing" which most people seem to think means "almost the same thing.")

So what underlies the conversation is this: You, the customer, do not trust my judgement, or you do not trust my character, so you are willing to spend over twice the amount of money. You, in other words, trust the drug company over me.

That's what irks me. That's what pisses me off.

So I dispense the brand and she pays. The drug company has won the battle this time, but did Don Quixote give up his fight for the Fair Dulcinea? No. And neither will I. Onward, over the next hill, the next mountain, onward to the plain of Truth and Fairness go I, and others; we shall win the war for the truth and vanquish the foes of Government and, Ack! the Drug Companies!

Monday, March 24, 2008

This from
Medical News: Campaign '08: Party Line Divides Views on Healthcare Campaign Issues - in Public Health & Policy, Campaign '08 from MedPage Today:
"For example, 40% of Republicans believe the U.S. healthcare system is better than other countries when it comes to making sure everyone can afford needed care. Only 19% of Democrats and 22% of independents share that belief.
Similarly, 72% of Republicans believe the U.S. offers better quality of care than other countries. Contrast that with the 49% of Democrats and 48% of independents who feel that way.

Huh? Now, I am a Republican, just so you know. More than 7 out of 10 Republicans think we are the top shelf in health care? 4 out of 10 think we can make sure everyone can get some kind of health care when they need it? Who are these people? Either they cannot read or they simple do not choose to read. But it isn't just the Republicans that live in fantasy land. About 5 out of 10 Dems and Independents also think we are the cat's meow.

I can only presuppose that these are the people who do not currently need health care. They are the one's who are twenty, maybe thirty years old and who think that getting sick means an occassional case of the flu or the common cold. Not needing a doctor they rarely go; not needing a prescription they do not know what a mess the current system is in. Ignorance, as they say, is bliss.

Unfortunately, nothing will be done in this country to turn our health care mess into a convenient and fair system until we all begin to look over the collective fence at our neighbors and ask the question:
How are they doing?

It isn't enough to look at your family and say, Gee, things are pretty good: my job gives me a nice income and I've got the best health care in the world.

No; you --we-- all need to look around, at our neighbors, our friends, our extended family. Heck, look at strangers: There but for the grace of God go I.

Is it right, is it fair, that 43 million people don't have any healthcare insurance at all??? 43 million people.

Is it fair that the guy coming up to my counter pays $10 for his Lipitor, but the next guy pays $50? Why? Well, the second guy had the bad luck to work at Company B instead of Company A. What has working for Company B have to do with health care? And what about the poor shlub who works for Comany Z? He doesn't get Lipitor at all because it isn't on the formulary.

Is it fair? No, obviously not. Well, then do something about it. Talk, listen, care. Then vote.

Sunday, March 23, 2008

And here's another crap-happy product: Mucinex. Technically it does work. They performed tests and it shows a minimal effectiveness over placebos. The real question is: Why shell out nearly $20 for something that works that badly? Just drinking a lot of water or juice will do nearly the same thing. They're selling snake oil again folks, and you're buying it.

Saturday, March 22, 2008

Finally! This week's Slate magazine (March 22nd) has exposed the cold remedy Airborne for the snake oil it is. The double blind study supposedly done wasn't, and the stuff will give you a good case of vitamin A overdose if taken as directed. All it is is some vitamins...but hey! it was "invented" by a school teacher, so its gotta be good...doesn't it?
Because it is basically a vitamin product the FDA doesn't have to say it is effective for what it says it is effective for (colds), but does that make any sense? If somebody comes out and says something will cure the common cold then it should give us some proof, right? (But then again, Oprah said it was great stuff so...?)
Or maybe we should all remember that if something seems too good to be true...then it isn't. True, that is. And remember, there is no cure for the common cold. Right? Right.
And one more thing: All you people out there wanting some product to get rid of your colds or the flu...THERE ISN'T ANY. RUN FOR YOUR LIVES...WE'RE JUST TRYING TO GET YOUR MONEY YOU FOOLS!
Why is everybody upset, saddened, and, yes, surprised when they are told that they have to wait--wait!--for oh, maybe an hour before their prescription is ready...when it is the day before (or after) a major holiday? How many holidays do we have to live through before we notice that it sure is crowded here after Christmas, Labor Day (doctors tend to take the holidays off, people!), Fourth of July, Thanksgiving, etc.
Wouldn't you think that after, say, ten years--twenty, thirty?--we'd start to get the drift?
But no. Here is a sixty-something woman dropping off a bag full of refills at the counter on Good Friday. Could she have called them in the day before and waltzed right up to the counter and just picked them up? Yup. But now there is a line backed up to the men's toilet and when told she might have to wait an hour she seems rather disgruntled.
Well too bad, lady. Yer waitin'.

Wednesday, March 19, 2008

The New Mafia





Kay: It made me think of what you once told me: "In five years the Corleone family will be completely legitimate." That was seven years ago.
Michael Corleone: I know. I'm trying, darling. But things aren't as easy as they seem. The government pols are giving us money hand over fist. It just wouldn't do to turn them down. What would the Godfather think?

Kay: Michael, is it true?

Michael Corleone: Is what true, Kay?

Kay: That you've never intended to get out of the insurance mafia and into a legitimate line of business? Is it true?

Michael Corleone: Don't ask me my business, Kay.

Kay: Is it true? Is it, Michael?

Michael Corleone: No. Don't worry. We'll get there.

Kay: Michael, they said that you killed that girl, Nataline Sarkisyan. When she needed a liver transplant you said no and she died. Said it cost too much.

Michael Corleone: Kay, it's a lot more complicated than that. The doctors and the hospital, they never sent the right paperwork. We were waiting and waiting. But the prior authorization never could get done. You got to send the proper paperwork, Kay.

Kay: The DA is going to prosecute you people for manslaughter.

Michael Corleone: Kay, they can't. The government has exempted us. You can't sue insurance companies anymore. We're bigger than than U.S. Steel, Kay. We have now what we have always needed, real partnership with the government.

Kay: Who are you, Michael? I don't know you anymore. My friends say you're nothing but stupid thugs. People behaving like that with authorizations and formularies, deductibles and copays. Thugs, Michael! But they're going to change things this time, Michael. Hillary and Obama, they're going to change everything so the insurance mafia will be put out of business.

Michael Corleone: Please. If anything in this life is certain, if history has taught us anything, it is that you can kill anyone.

Kay: Michael, are you saying what I think you're saying?

Michael Corleone: Yes, Kay. We're willing to with-hold authorizations on even the president of the United States. He—or she—won't be able to go to the dentist without our OK.

Kay: You wouldn't dare.

Michael Corleone: This is the business we chose.

Kay: The doctors won't go along with you. They'll put you out of business.

Michael Corleone: How Kay? Who do you think pays the doctors? Me, and my business partners. If a doctor was to, say, try to make it on his own, God bless him, then we'd just have to make him an offer he couldn't refuse.

Kay: What would that be, Michael?

Michael Corleone: We might just send—hypothetically speaking, of course,--Luca Brasi to hold an audit to the poor guy's head, and then assure him that either his signature or his college loans would be on the release. And maybe—again,hypothetically, of course—suddenly all this guy's procedure's come up “experimental.” We don't pay for “experimental,” Kay. They usually end up signing.

Kay: You know what I saw on the news, Michael? There were about 150 nurses picketing the CIGNA headquarters—CIGNA, Michael, that's one of yours isn't it?--and maybe an hour goes by and they say that they made a mistake and Nataline can have her liver transplant.

Michael Corleone: What does that tell you?

Kay: It means they could win.

Michael Corleone: Don't you know that I would use all of my power to prevent something like that from happening, Kay? There's more money potential in medicine than anything else we're looking at. Now, if we don't get into it somebody else will. Maybe the Tattaglia Family maybe all of them and with the money they earn they'll be able to buy more police and political power. Right now we have the prescription business and we have the unions and those are the best things to have. But lab costs are a thing on the future. If we don't get into it now we risk everything we have. Not now but ten years from now. I'm telling you Kay, good health is the most important thing. More than success, more than money, more than power. And good health costs, it costs big time. But someday Kay, maybe not this year, but someday things'll get better, things will be different. I'll change; I'll change. I've learned that I have the strength to change.

Kay: I hope so, darling, because this is getting too violent for me!


There was a letter in the local paper decrying the evil of "socialized medicine." Since that letter appeared there have been a few follow-up replies. Those responding seem to feel that no system could be worse than what our country currently offers. They point out that we as a nation spend 15% of our gross national product on health care, far more than any other industrialized country in the world (those bad socialist countries France and England are 10% and 8% respectively), but that our care is currently lagging behind the rest of the world (107 health disease deaths per 100,000 people versus 40 in France). One guy pointed out that the health care that our wonderful public servants currently have is actually government administered...that is, socialist. Wonder why they did that? Maybe they figured they didn't want to be hassled with prior authorization requests and formulary changes. Maybe they just figured that this terrific system of private insurance companies (the American way, after all) was getting too complicated. And then maybe they just wanted a health care system that worked.

As a dispenser of medicine there is one redeeming virtue to the current crisis: I get to yell at the insurance bureaucrats after they give me a hard time on the phone. It's so cathartic. It's probably the best thing about the situation we're in, maybe even reducing my chances of having a coronary. Hope so, because God help those of us needing treatment for something.

A manual for filling a prescription


Twenty-five years ago I graduated from a five year program for pharmacy, a veritable manual for dispensing medicine, if you will. I realize now that these times demand a manual for picking up one's prescription. Fortunately you do not need a five—now six—year degree. But there is still a need for preparation. Times have have been a'changin'.


One: Prepare to wait. (See following.)


Two: If you have a new insurance card bring it. You may think we pharmacist's copy it or run it through some swipey gizmo but we don't. It does, however, have a phone number on the back of it so we can call and find out the numbers we need for billing. The numbers on the face of the card are a trick: they are probably wrong or missing entirely. Sometimes the insurance company puts a few letters in there to try and trip us up and we need to call and find out which letters we can ignore. Anyway, we need the phone number to call the company and get the information we need (after being on hold for twenty minutes).


Three: Please let us know how to spell your name, as we cannot read the doctor's writing. Don't worry, we won't guess at the pills; we will call the office and ask what the medicine really is supposed to be. No we won't actually speak to the doctor; he is busy. And no, we won't actually talk to the nurse; she is busy too. But we can get in touch with the secretary. If she can decipher the handwriting (she can't) we'll be all set. See step one.


Four: Here is a little hint: The word is pronounced GEN-AIR-IC. Not GEN-ET-IC. That just irritates us. And yes, they are the same as the brand. Many of the GEN-AIR-IC drugs are the brand drugs put into different molds or just different bottles. If you like the fancy labels just tell us and then we can charge you more. Otherwise we are going to try and save you money, though some people don't like that.


Five: Some people like to think we only have to count some pills and stick a label on. Not so. We do really look for dangerous stuff, like interactions and allergies and doctor mistakes. Sometimes we play a little game and see how many mistakes we can catch in a day by doctors. Wrong drug. Wrong strength. Maybe wrong patient (that one's a hoot!). But most of the time is spent on the phone calling the insurance company (see step one). One caveat: if you want fast service DON'T STAND AT THE WINDOW TAPPING YOUR FINGERS AND STARING AT THE PHARMACIST. We like to put those people at the end of the line just to irritate them as much as they irritate us. One of the few little chuckles we get in the day.


Six: If you think it is funny to show up at the drop-off window thirty seconds before we close for lunch and say “I just made it!” it isn't. You're going to wait. And wait. And wait some more.


Seven: After a half hour, go to the pick up window. The prescription isn't going to be done, but we can then tell you why it isn't done. That gives us a measure of satisfaction; we can at least tell you that we are working hard to try and put the squeeze to your insurance company because they have rejected your prescription. We like to tell you how much we hate the insurance companies because, well, we really hate them a lot. We especially hate them for telling us all of this rigmarole is because they are saving everybody so much money. I know they aren't saving anybody anything—well, they do save themselves some money—and to hear that more than once a day is just the worst.


Eight: Go back to the waiting area or shop some more. We have to call your insurance company again since they rejected the claim. This is kind of funny, or would be if you weren't the person calling or the person waiting. You see, the company we call isn't really the insurance company. No. Your insurance company contracts out the billing to a second company. That is who we are now calling. That way the person “helping us” can say “I'm sorry; the insurance company does not allow for this drug, but you can call 1-800-BLA-HBLAH and they can assist you.” So we get to call someone else. So they can help us help you some more.


Nine: Go back to the counter. We can then tell you that we are very sorry (we really are) but that your insurance did not allow for the drug your doctor selected. However we can call your doctor (see step three) and tell them that (they love to hear from us). They can then call your insurance company. Not the company we call, but the real insurance company...unless that company lets the other company do that authorization thing, but it's kind of hard to tell which does that sort of thing, but after a few calls the doctor will find all that out, don't you worry. This is the iffy part. If your doctor does not yell loud enough, or, sometimes, cry, you might not get what you need. We are sorry about that. We are also sorry that when you ask us to call your insurance company and see if we can't straighten this mess out, well, forget about it. How long will it take? Um, no idea.


Ten: See step one. You see, we've just gone through the above steps for every person who was ahead of you, so we are now so backed up we're really just playing parchesi back here. Hey, it beats

talking to insurance companies.

Saturday, March 15, 2008

Hit Clear?--
That will be $19.98. Will you please sign for the prescription insurance billing? Yes, right here on the signature pad. "Cancel"? No, hit "Continue." Yes, the button at the lower left. The one that says "Continue". Thank you. Now sign...no; I'm sorry, you've hit "Accept" before you signed your name. Let me reset the pad. There, now you can sign your name. Yes, that's right. Hit "Clear"? No; "Accept." Whoops, you hit "Clear." "Clear" actually clears the pad so your signature is erased...or cleared. If you hit "Accept" then your signature will be...yes, accepted. Try it again. There you are. Now that wasn't so hard, was it?