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Sunday, March 29, 2009


 

In Bruce Weber's latest book, "As They See 'Em: A Fan's Travels In The Land of Umpires," he wonders a bit at why someone would put himself (note: they are all men) in the position of being routinely spat on, cursed, and hollered at. I realize that I too could have been a baseball umpire. All of us in retail pharmacy, it seems to me, have the requisite training and inherent abilities to be a big league ump.

 

I've had spittle discharged in my general direction as a matter of course. Cursed? Practically every hour of every day. Yelled at? Please. Only the linoleum saves my shoes from being covered in dirt. 

 

And the comparison does not stop at the abuse. Pharmacists, like umpires, must make split second decisions and then move on, ready for the next. I continue to recall the episode on "I Love Lucy," where Lucille Ball gets a job in a chocolate factory. The chocolates speed down the line faster than she can pick them up. Finally she begins to shove them into her mouth. (I don't recommend that for any but the choicest medications.) In my pharmacy we do about one script every couple of minutes. That's a pretty good pace, especially when one of those insurance rejections comes up and we have to stop "the line" to make a phone call to an insurance company that puts you on hold for twenty minutes, then transfers you to the other department that you should have called (if you only knew of its existence, that is). 

 

For every prescription coming down the line, unlike those chocolates, you have to make decisions. Is this the right dose? Did the doctor write for the wrong drug or the wrong strength? Does the Nurse Practitioner really know what is going on here? Did the Physician's Assistant hit the wrong button before sending his e-script? Is the patient still taking drug X which interferes with Drug Y? On and on it goes.



Just like umps, those unlovable bumps on a log getting their lumps. Oh, how I envy them! How wonderful their lives must be! For though they receive their abuse as I do, though they have to take it all with a fair dose of equanimity, as do I, they have that not so secret weapon, that discharging of duty up their sleeves—Oh, how I would love to say it, just once, to Mrs. Scrofulous, to Mr. Pin Head!

Crouching low then leaping high, brazen and loud, sung like a Metallica screech:



Yerrrrrrr Outtttttttta Heeeeeeeeeerrrrrrrrreeeeeeeee!

Thursday, March 19, 2009

It all depends on who you talk to.

So I'm filling a prescription for insulin. Simple right? Nope. Not anymore.

The prescription for NPH insulin, an intermediate acting insulin, had been filled and refilled many times for this person. But this time her insurance rejected the claim. Apparently, as the rejection showed on the computer screen, it needed a prior authorization. For those of you not yet aware of this little bug-a-boo, this is when the insurance company says that the doctor needs to make a written statement showing that the treatment is indeed necessary, otherwise the insurance will deny. This is usually encountered for high priced medications new to the market. Usually a drug like Coreg CR or Ambien CR, where the drug maker reformulates to make it last longer but where the real benefit comes to the company making the drug because it gives them another year of patent life. But for insulin? Why would insulin need a prior authorization?

So I call. I get this nice sweet voice on the line and I explain that there must be a mistake, that no company—not even an insurance company—would make insulin non-reimbursable. She said that, yes, she understood; but the rejection was correct. They really did require a prior authorization. What about other maker's of insulin? Wouldn't they be OK? Maybe it was just the particular insulin we were using that would be rejected. Unfortunately, no, she said. All insulin would be rejected—except for Novalog, she explained. Well, that wouldn't work, I told her. Novalog was a completely different type, and not interchangeable. Could she just check one more time?

Another problem for me was that she was just too sweet sounding to yell at. I, as other posts here have attested to, enjoy the odd phone call to protest the great injustices that insurance companies inflict on us. But here I was totally disarmed.

I make a note in the patient's file that she would need to get an authorization from her physician, and I faxed the request to the doctor's office.

Two days later I see that the insulin was dispensed and sold—without any authorization on the part of the insurance! One of my staff pharmacists, the day after I spoke with the insurance company, called them and, getting someone different, was told that Oh, it was just a mistake and just to re-run the claim and it would go right on through just as easy as you please.

Well, ain't that something. It just goes to show you that it depends on who you call. If you don't like the answer, just wait a bit and call back. The next person might actually know what they are talking about.

Sunday, March 15, 2009

Bad bugs the new white meat?

As reported by Nicholas Kristof in The New York Times recently (Sun, Mar 15th, "Pathogens in Our Pork), hog farms are now infected with the dangerous bug known as MRSA (pronounced "Mersa"). As estimated by the University of Minnesota, up to 39 percent of pigs on hog farms harbor the superbugs which are resistant to almost all forms of antibiotics. (More people die from MRSA in the United States than from HIV.)

Why? Same reason as why doc's give out prescriptions to treat viral infections like colds and ear infections: mis-use of antibiotics. As Kristof writes, more antibiotics are given to livestock in North Carolina alone than goes to treat the entire U.S. population.

This is all due to the tremendous leverage that the agribusinesses have on Washington politicoes. The citizenry is being plowed under for the sake of increasing the yield of hog, cow and chicken farmers.

It's as if the Congress is doing as Marie Antoinette, saying instead, "Let them eat pork!" I wonder how the average North Carolina congressman/congresswoman would feel if we rubbed a pork pie in their faces? Penicillin anyone?

Monday, March 09, 2009

From Economist.com (Mar 9, 2009, "The view from West Virginia"):

[Obama] insists that Americans who like the health insurance they currently get through their employer can keep it. But Michael Tanner of the Cato Institute, a libertarian think-tank, predicts that government insurance will crowd out private insurance. The government could offer insurance cheaply by dumping part of the cost on future taxpayers, and so crush its private competitors.
If that happens, hospitals will be squeezed. Currently, patients with private insurance cross-subsidise those in government schemes. (A typical hospital enjoys a profit margin of 48% on each privately insured patient and suffers a 44% loss on each patient covered by Medicaid, the government programme for the poor, according to McKinsey, a consultancy.) If that subsidy disappears because there are fewer private patients left to pay it, hospitals will have to cut back. European-style queues may form, the sceptics fret.


Firstly, why would anyone keep the crap insurance they now have? That's what I want to know. Too expensive, too many restrictions, and too bothersome. Oh, and too wasteful and unfair.

Second, I don't believe the statement that a typical hospital enjoys a profit margin of 48%. Why? Because I've seen this kind of statement before, usually on the financial records of insurance companies. These kind of statements are all pie-in-the-sky reports. They count on the credit side anything and everything, but leave out all the waste and the instances that debits pile up off the books. It's like Aetna or United Healthcare saying that they've saved the average customer X amount of dollars. Yeah, IF you don't count all the time and money you've pushed off onto doctor's offices (hiring new staff for all the authorizations and phone calls) and pharmacies (ditto).

It's easy to say you've saved everyone SO much money IF you don't count this and that.

Sunday, March 08, 2009

What now, Republican?

David Frum in the Mar 7 Newsweek sums up Rush Limbaugh pretty well:

And for the leader of the Republicans? A man who is aggressive and bombastic, cutting and sarcastic, who dismisses the concerned citizens in network news focus groups as "losers." With his private plane and his cigars, his history of drug dependency and his personal bulk, not to mention his tangled marital history, Rush is a walking stereotype of self-indulgence—exactly the image that Barack Obama most wants to affix to our philosophy and our party. And we're cooperating! Those images of crowds of CPACers cheering Rush's every rancorous word—we'll be seeing them rebroadcast for a long time.

Why is that important for a pharmacy blog? Because if you are a Republican, as I am, your party may well be responsible for either sidelining universal health care or watering it down to where the insurance mafia wins what it needs to win for its survival.

As Rush becomes the arbiter of Republicanism, congress increasingly becomes the stop sign on the road to legislation. Of course we might want to wait until 2010 when Obama could go around to the various districts and wave the flag for the Dems (I expect--who doesn't--a landslide Democratic majority in 2010). Then bills will be able to slide along the path to fruition more smoothly.

I personally think the Republican party is doomed to extinction or a long hibernation akin to the post-Depression politics of Roosevelt.

There is a third way: treat Republicanism as a trait, an idea that can be afixed to a certain topic, but not necessarily to the whole shootin' match. For instance, those opposed to abortion such as myself, can be conservative on that topic, but on health care we can be free to oppose the Limbaugh-ites and exercise our minds again to oppose the insurance mafias for the betterment of mankind. We can be the superheroes of the real world. We will not be limited to the dogmas of some blowhard, driven to a slouchfest of behemoth proportions, smoking cigars in back rooms and making nasty comments about our president. No, we will be more in keeping with the way that McCain has transformed himself, advising the president where they both agree, but loyaling opposing him when his conservative principles dictate that he should do so. We will be the real independent party, whereas the Independent party is really just the Democratic party.

We will be the Watchmen for the new world!

Tuesday, March 03, 2009

We want the best and we want it now!

As The New York Times reported today (A Hurdle for Health Reform: Patients and Their Doctors, Mar 3, 2009), what fundamentally drives the costs in America's health care system is the desire on the part of doctors and patients for the best--meaning the costliest to most--new treatments and medicines. It doesn't matter if the upside is slim to none. Stick a high price on something and a few slick ad pages and Bam! you've got a winner on your hands. Ever check out the number of beta-blockers out there? How about ACE inhibitors? Gazillions and none of them work appreciably better than the first ones out of the block twenty-five, thirty years ago.

The Times cited a 2004 study (published in The American Journal of Public Health) that showed that only 1 in 16,000 people benefited from recent technology as regards their health.

Today I finally convinced someone not to bother with Tamiflu for her daughter. Was I being too harsh? You decide. Her daughter had had the flu already for three days. Tamiflu needs to be started quickly, at the onset of symptoms. Even then the average flu symptoms will disappear only a half day before they would have without Tamiflu. Would you spend nearly $100 for half a day's symptoms (which would be alleviated anyway with some ibuprofen or naproxen)? I wouldn't and that's what I told her. She said she wouldn't either.

You got your diet, your exercise, your vaccinations, your indoor plumbing, and good old clean water (to drink AND to wash your hands). Everything else is pretty much luxury.

Sunday, March 01, 2009

The return of Harry and Louise?

Remember those ads featuring Harry and Louise, the middle-aged couple worrying over the governments plan for national health care back in '93? Largely credited for destroying Clinton's plan for the country they are back. Last year, during the 2008 Democratic Convention (and the Republican Convention as the Dems paid for the ad to be aired then too--smart!), the two were reprising their role, this time to explain that too many people were "falling through the cracks." Even the lobby--America's Health Insurance Plans--that created those original ads says it wants to play a different role this time (see The New York Times, Sun, Mar 1, 2009, "Liberal Groups Are Flexing New Muscle in Lobby Wars").

Well, good. Maybe Obama has the political momentum to get this done. I do think he has given too much power over the details to congressman. Who do you trust more to deal with this problem, Obama and his policy wonks, or those congressmen who've been bought and paid for by insurance company lobbyists all these years? Yeah, I thought so.

Check out the National Coalition on Health Care, and give them your support. Go Obama!