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Friday, February 26, 2010

Who'd a thunk it? Health Care Debacle Leads to Love!

As reported in The New York Times the awful U.S. healthcare "system" has one shining virtue: It forces people to marry.

Philip Swift wanted to marry his sweetheart, Katie Robbins. But she didn't seem to want the commitment, in a reversal of the normal man-commitment-phobia. Three years went by and Mr. Swift developed kidney stones.

Mr. Swift, like millions of other Americans, doesn't have access to health care. But Ms. Robbins did. Thus:

Katie and Philip
Sittin' in a tree.
M-E-D-I-G-A-P.

Sunday, February 21, 2010

The future of pharmacy

Which is better, a store with many registers where you have to guess which line will be faster (think Wal-Mart, Target, grocery stores)or a store where there is but one queue, one line, and where you are directed to a eventual open register (think Best Buy, Marshalls, TJ Maxx, Borders)?

Well, Richard Larson, an engineer at MIT, but also known as Dr. Q--a "queue psychologist"--says that there are definite advantages to the single queue line. Though wait times average the same, anger issues are lessened by the knowledge that there is a definite first-come, first-serve.

There is also an advantage to the store. While Q-ing up, your attention is focused on all the little things up for sale along the way whilst you wait. Nice for impulse buys (always high profit items for stores).

But while Q-ing up at a local Marshals, I thought of another advantage to such a queue: privacy. Here I was waiting for a register with a pair of pants and socks, and I noticed that I was about fifteen or twenty feet from the nearest register. I couldn't even hear what was being said by the clerk or customers. Now wouldn't that be just the ticket for a pharmacy where some druggist has to explain to some poor bloke about his ED drug, or some woman about her miconazole?

If you've been at a drug store lately you know how the procedure works. You pick up your medication at the register and if you want to be counseled there is a little window cubby just to the left or right where you scoot yourself to so that there is "privacy" and the nosey-nancy just to your right can still hear every word. And usually the pharmacist is so busy he/she tries to counsel the person right at the register but getting the person to say all the "private" things so they aren't liable for HIPAA (Health Information Portability and Accountability Act).

Wouldn't it be great if pharmacies had a system like Marshalls, and the other people couldn't overhear private, sensitive conversations that are really none of their business?

Thursday, February 18, 2010

Mail Order Prescriptions?

Mail order prescription service is now 6.7% (as of 2008) of all retail prescriptions sold in the U.S. That's 238 million scripts...and growing.

Want to know what happens--and the pitfalls along the way--when filling your prescription through mail-order? Well, follow along.

1) You've got the prescription from your doctor. You need to contact your PBM (that's your Prescription Benefit Manager which you probably think is your insurance but really is a partner with your insurance). The largest PBMs are Express Scripts, Caremark, and Medco. They will send you a form--maybe you already have it--for you to complete and send in along with your prescription. But wait--before you lick that envelope take a good look at that piece of paper. (It would be better to do this at the doctor's office, but if your already home, don't worry.) Looking at the prescription, does it look right to you? Any mistakes? No? Good, but it's a good idea to fill in your address, or better, write it on the back of the prescription along with your phone number and date of birth. Also, any allergies or any information that would be pertinent. If you did find something wrong, call the doctor and have them fax the correct prescription to the PBM/mail-order company. If your doctor agrees to fax prescriptions (almost all do) you can save yourself some time and trouble and just have the doc do that when you're at the office. Just be certain you have the correct fax number. Double check them!

2) So you've sent out the prescription. What actually happens to it? First it gets scanned into a computer system, front and back, along with everything else that came in the mail: order forms, even the envelope! Data entry technicians then enter the information from the scanned prescription (they're looking at a computer image, not the actual piece of paper, which is filed away). Now do you see the importance of a well written or typed prescription? Any ambiguity here gets put into the computer and if not caught will result in your not receiving the correct medication. Good handwriting counts! Also, if the prescription is clear and read easily you will get your medication in a much shorter time interval than one that has to be sent back to the troubleshooters who then have to call or fax the doctor and start all over again. The prescription is then sent on to its next station, DI (Drug Interaction). There it is screened by pharmacists specially trained in drug interactions for any possible problems that might occur with other meds you are taking, even over-the-counter medications (be sure to fill out all the information on the forms: think pain relievers, herbals, vitamins, diet pills...anything).

3) If and when all the problems are taken care of the prescription then goes to the insurer who if they agree to pay for it then sends the prescription back to a pharmacist verifier, who compares the prescription image with the entered data. If it matches up fine it goes to a fill center, often not even in the same building as the pharmacists checking the prescription. Do you picture these places as giant warehouses where pharmacists are busy counting pills by fives on counting trays? Um, no. They are giant, though: Medco has one that is about as large as six football fields. Express Scripts--the nations largest PBM--has one coming online next April that will fill 110,000 prescription in a single day! But not by hand. By robots. These places all fill by robotic machinery: it's safer and faster.

4)The prescription once it is filled is put into a shipping container and put in the mail.

From start to finish it should take two weeks. But that is IF there aren't any snafus along the way. The most common reasons for longer waits are bad handwriting and errors by doctors. If either occurs then the pharmacists or technicians --or both-- have to contact the doctor and that can take days. That's the reason you should give the prescription a good look-see before you send it off. Errors are very common. Very. Saves you time to look before you send it out.

One caveat: if you're sending out a prescription for a control drug, DO NOT CHANGE ANYTHING ON THE FACE OF THE PRESCRIPTION. It could be considered as altering a controlled prescription, which is a felony. Not a smart thing to do. Better to write something down on the back of the prescription, or attach a note.

Monday, February 15, 2010

Speed kills

Ken Lawton of Newfoundland has a point in his blog. It's not necessarily speed that kills, but recklessness. Not merely a fast driver, but a fast, drunk driver. Or a fast impatient impatient driver holding a cup of coffee and talking on his cell phone while driving with is knees. That sort of thing.

The illustration made me think of what happens in pharmacy. It isn't necessarily how fast we fill prescriptions that causes us make errors, but the lack of focus while we are filling at the speed of light. Try filling a prescription every minute or two WHILE answering the phone, counseling a patient, troubleshooting some insurance rejection and answering a technicians question...oh, and the computer just went on the fritz. Great!

That's what leads to errors, and why people end up in the hospital, or in a grave.

Robots can fill ridiculously fast...and accurately. But you start to introduce the human element in there with all that other multitasking stuff...watch out. You're playing with fire.

What to do? I honestly don't know, except this: check your own prescription meds and find out as much about them as possible. Because truth to tell your pharmacist is too overwhelmed to deal with any of it. That's the honest truth of it. Might as well say it and be done.

Saturday, February 13, 2010

The Christian Church and Climate Change

Persnickety is branching out...

I began this blog as a way to teach others what pharmacy is really about; it was my intent to show life within the profession to those outside.

I want to branch out now to other ideas, and focus on all the things that it takes to make me persnickety. What riles me, what disgusts, nauseates and sickens me. All of my little pet bete noires that lurk in the shadows of my own particular dark forest.

Up for discussion right now is the prospect of global warming, better known as climate change.

I've been so nauseated recently by the comments of right-wing congressmen who've felt compelled to be ironic now that Washington D.C. has received a couple of snowstorms. "It's going to keep snowing in DC until Al Gore cries 'uncle,'" tweeted Sen. Jim DeMint, R-S.C.

I understand why Republicans are against the idea of climate change. If the science is accurate then businesses are going to have to pony up and thus they pay to have their congressmen/women vote in a more business-friendly way. I understand that. It is the way of the world.

What I do not understand is the view of my fellow Christians. Like their views on the healthcare debate, I feel them to be on the wrong side. Shouldn't Christians want to help the unfortunates who find themselves without adequate or any insurance coverage? Shouldn't they advocate for the oppressed and the sick? Likewise shouldn't Christians exhort, as Jeremiah did so many years ago when he said, "I brought you into a fertile land to eat its fruit and rich produce. But you came and defiled my land and made my inheritance detestable." (Jeremiah 2:7 NIV)

What is it about the modern Christian church? Does it beat in lockstep with the Republican Party on every bullet point of its platform? Will it sell its soul to the devil for the purpose of power politics? Did it not learn its lesson during the Reagan and Bush eras, when though aligned with the right it failed to produce any meaningful legislation that could in any sense be called Christian (prayer in school, abortion)?

The Christian Church needs to define itself not by the party in power, not by political means, not by picking sides in a liberal vs. conservative drama, but by the words of Christ, and Paul and the apostles. "Since what may be known about God is plain to them, because God has made it plain to them. For since the creation of the world God's invisible qualities—his eternal power and divine nature—have been clearly seen, being understood from what has been made, so that men are without excuse." (Romans 1:19-20 NIV)

Friday, February 12, 2010

Wait just one sec; I've got to interrupt Newt's fancy schmancy song and dance with this bit of reporting hot off the presses (see Nadja Popovich's piece on NPR.org or http://www.npr.org/blogs/health/2010/02/insurers_post_big_profits_cut.html).

According to documents filed with the U.S. Securities and Exchange Commission, over the last five years the big five health insurance companies' profits have soared to 56 per cent since 2008. That's UnitedHealth Group, Wellpoint, Aetna, Humana, and Cigna. (Aetna was the only one of the five to not post an increase.)

How'd they do that? I mean, especially with the recession and all. Well, according to Avram Goldstein (head of Health Care for America Now, and advocacy group), all they had to do was raise their rates and increase the cost burden for the little guy AND drop 2.7 million sick people who were Oh such a drain on the corporate coffers. So higher premiums, higher copays, made for a nice little "cha-ching".

Now the company CEOs will tell you that the 12 billion dollars in profits during last year alone (remember...a recession year)amount to a mere drop in the sea. A mere penny on the dollar. But as Goldstein makes mention, that penny, if added up over ten years, amounts to $250 billion dollars that America could have saved itself. Not to mention that if we did not have to pay the duplicative administration costs for all these plans (ten thousand prescription plans in the U.S. and counting)...well, we're starting to see this as real money now aren't we?

One thing I can't figure out. How the heck could Aetna lose money when this is a rigged system? They must be real bozos...or nice guys. We all know nice guys finish last in the insurance biz.

Thursday, February 11, 2010

Newt's Tip #3 of our continuing saga:

• Meet the needs of the chronically ill. Most individuals with chronic diseases want to be in charge of their own care. The mother of an asthmatic child, for example, should have a device at home that measures the child's peak airflow and should be taught when to change his medication, rather than going to the doctor each time.

Having the ability to obtain and manage more health dollars in Health Savings Accounts is a start. A good model for self-management is the Cash and Counseling program for the homebound disabled under Medicaid. Individuals in this program are able to manage their own budgets and hire and fire the people who provide them with custodial services and medical care. Satisfaction rates approach 100%, according to the Robert Wood Johnson Foundation.

We should also encourage health plans to specialize in managing chronic diseases instead of demanding that every plan must be all things to all people. For example, special-needs plans in Medicare Advantage actively compete to enroll and cover the sickest Medicare beneficiaries, and stay in business by meeting their needs. This is the alternative to forcing insurers to take high-cost patients for cut-rate premiums, which guarantees that these patients will be unwanted.


Here's where it all becomes laughable. Let's "meet the needs of the chronically ill." Yeah, isn't that what insurance is for? Isn't that the purpose of insurance? Unfortunately insurances don't have to take anyone who happens to be chronically ill? Have back pain? Sorry, it is a pre-existing condition so not covered. Diabetic? Sorry. Mentally ill (depressed? bipolar?)? Have migraines? How about high blood pressure? Nope. All pre-existing conditions and you won't be eligible for any new plan. Now Obama's bill will change that...IF the Republicans allow passage. A big IF.

Oh, and Newt. Just for your info, patients already have devices to monitor asthma. They're called peak flow meters and the cost about $20. But they're not usually covered under anyone's insurance.

As for HSA's (Health Savings Accounts), I used to think these would be great. As a matter of fact, I thought they were the answer to all our healthcare problems. Not any more. I had one for two years. The theory is that since you control the money, you will shop around and get the best quality care for the least money. The consumer controls the money. Smart huh? Not really. You see once I tried to find out what a doctor would charge, what a hospital would charge. You can't do it. You can't even find out exactly what doctor is going to be charging you for what. It is all a mystery until about a few months later when all the bills start showing up. And then, of course, it is too late. Control the money? Forget about it. The system is rigged and you aren't going to be able to do a thing about it.

Now for the kicker: Newt writes of somehow tweaking insurance into "special needs" away from the be all things to all people model. Hello? Aren't we talking about insurance here? We need insurance for those illnesses that we already have AND for those we don't already have. That is, for those times we get sick...in the future...in the unknown unforeseeable future. Newt then continues the idiocy, writing that this is "forcing insurers to take high-cost patients for cut-rate premiums, which guarantees that these patients will be unwanted."

See? That's the problem: Republicans like Newt see this crisis as an attack on insurance companies and their profits. "These patients will be unwanted." Duh...they're sick. They cost the companies money. Anyone who files a claim with an insurance company is by definition "unwanted." That is the problem with having a "system" maintained by for-profit businesses. Get it?
Continuing our Newt's Greatest Ideas About Healthcare, his second bullet hits close to the mark, kinda:

• Make health insurance portable. The first step toward genuine portability—and the best way of solving the problems of pre-existing conditions—is to change federal policy. Employers should be encouraged to provide employees with insurance that travels with them from job to job and in and out of the labor market. Also, individuals should have the ability to purchase health insurance across state lines. When insurers compete for consumers, prices will fall and quality will improve.

I've put the key words in bold. Making insurance portable has been one of those EUREKA ideas for quite a long time. People lose their jobs and find that they are quite vulnerable to catastrophic illnesses that can bankrupt them. Or worse. What's worse than bankruptcy? How about death? It's well known that every two months as many people die from our so called healthcare mess than died in the World Trade Center attack on 9/11. So you could say portability is kind of important, yes?

Except nothing has been done about it. Nothing. Why is insurance even tied to employment? That was a WWII gimmick to give businesses an upper hand to recruit people as they couldn't raise wages in wartime.

Now to those two key words of Newt's. First, "encouraged". Love it. We'll "encourage" companies who currently don't give a good hot darn about their employees--except of course for the bottom line--to shop around for some insurance that could be portable...for the good of their employees! Not for the bottom line...nobody cares for that do they? Of course, Newt might have some financial incentive in mind, but unless it would knock the socks or stockings off the CEO, well, it just ain't happening. And given the current double digit increases in premiums...don't count on this affecting anyone's insurance savings.

The other key word, purchase, is just such a quaint idea isn't it? We all should have the ability to purchase our own plans across state lines. Across state lines? How about the ability to purchase any kind of plan anywhere?

Prices will fall, and quality improve. Well, maybe in Newt's dreams, but here in the real world, it's going to take a whole lot more that Republican dreams.
Continuing our Newt's Greatest Ideas About Healthcare, his second bullet hits close to the mark, kinda:

• Make health insurance portable. The first step toward genuine portability—and the best way of solving the problems of pre-existing conditions—is to change federal policy. Employers should be encouraged to provide employees with insurance that travels with them from job to job and in and out of the labor market. Also, individuals should have the ability to purchase health insurance across state lines. When insurers compete for consumers, prices will fall and quality will improve.

I've put the key words in bold. Making insurance portable has been one of those EUREKA ideas for quite a long time. People lose their jobs and find that they are quite vulnerable to catastrophic illnesses that can bankrupt them. Or worse. What's worse than bankruptcy? How about death? It's well known that every two months as many people die from our so called healthcare mess than died in the World Trade Center attack on 9/11. So you could say portability is kind of important, yes?

Except nothing has been done about it. Nothing. Why is insurance even tied to employment? That was a WWII gimmick to give businesses an upper hand to recruit people as they couldn't raise wages in wartime.

Now to those two key words of Newt's. First, "encouraged". Love it. We'll "encourage" companies who currently don't give a good hot darn about their employees--except of course for the bottom line--to shop around for some insurance that could be portable...for the good of their employees! Not for the bottom line...nobody cares for that do they? Of course, Newt might have some financial incentive in mind, but unless it would knock the socks or stockings off the CEO, well, it just ain't happening.

Wednesday, February 10, 2010

In todays Opinion (found at http://tinyurl.com/ybltpld) Newt Gingrich has deigned to give us his take on the healthcare debate. Obama said he wanted new ideas, and Newt has some, or thinks he has some. The question is, Are Newt's ideas just more Republican blather? Well, I thought we should look at his list, one item at a time. Here's the first bullet in Newt's gun:

• Make insurance affordable. The current taxation of health insurance is arbitrary and unfair, giving lavish subsidies to some, like those who get Cadillac coverage from their employers, and almost no relief to people who have to buy their own. More equitable tax treatment would lower costs for individuals and families. Many health economists conclude that tax relief for health insurance should be a fixed-dollar amount, independent of the amount of insurance purchased. A step in the right direction would be to give Americans the choice of a generous tax credit or the ability to deduct the value of their health insurance up to a certain amount.

Yeah, that's it! We'll just make it affordable. That'll fix everything. (OK, I'll back off a bit.) He's saying that the tax subsidies we currently give to the unions for their "Cadillac plans" should be given across the board to everyone...especially the little guy who has to buy his own stinking plans. Um, I'd like to meet that little guy. Currently the typical healthcare plan costs over thirteen thousand dollars a year. A pretty hefty sum to come up with if you're a little guy. How many of those "little guys" are there I wonder?

The thing that is truly ironic about this idea is that...he's right on the button about one thing: Just let's make it affordable! Oh, not by using tax credits allowing "the little guy"--who is actually pretty much a figment of his imagination--to buy his own stinking insurance, but by actually making insurance so inexpensive that everyone gets to have the same quality care.

Not possible, you say? Well, they do it in England, Canada, France, Germany, Japan (are you going to make me write all the countries in the industrial West? Thank you!). But not here. Here we like to subsidize the private insurance corporations allowing them to soak the public and make gazillions of profits which in turn allows said companies to buy themselves representatives and senators who then vote for more subsidies giving them more profit allowing them to buy even more representatives...

It's the American way. And it seems to have worked quite well. Up until now.

Up next: Newt's Great Idea #2!
We're being invaded by Canada!

Pretty soon we're going to just have to institute the dreaded National ID card...just so we can lock our ER doors to those pesky neighbors to the north. At least that's the impression given by FOX "News".

“This should be a wake-up call to Congress and the administration,” said a Fox News medical commentator. “It is a fact beyond dispute that the United States remains the global destination for patients from all over the world.” Canadian conservatives weighed in as well. “It’s symbolic,” said Brett Skinner, president of Canada’s right-wing Fraser Institute. “These services are not available at all, or not available on a timely basis here in Canada.”

As Daniel Johnson of Salem-News.com states (in much nicer terms which I feel are lost on FOX) these allegations are lies.

What the FOX liars don't tell you is that the folks who come down south (41,000--if true--are a drop in the bucket of the people being treated in America) are seeking "boutique" treatments (limos at the airport, concierge service, etc), which if they can afford it, fine. It's their money; let them spend it as they wish.

What isn't stated in such very fine reporting is the "snowbirds" flying south from Canada, who live in retirement homes in the south of the U.S. Where do they get their healthcare? Why back in the good old Canadian system, of course. If the U.S. was so superior why wouldn't they get it here? Because in Canada they get it less expensively and its better care.

Also not mentioned in the FOX report is the fact that Canadians have better care after their heart surgeries resulting in less readmissions than in the U.S.

So, to sum up, in the U.S. we get sub-par healthcare AND we pay more for it. Great, huh?

As Mr. Johnson states, "The Canadian health care system is at least as good as the U.S. system across the board. At the same time, it’s less expensive and, with most procedures, has a lower re-admission rate because patients tend to be treated completely at the outset. The Canadian system doesn’t treat many Americans who want to come north because of the punitive malpractice system the Americans have.

One thing not mentioned are the number of so-called “snow birds”, well off Canadians who retire to the southern U.S. They keep their Canadian citizenship so they can readily return to Canada for medical care. This is something not available to Americans."

Yeah, and if we listen to the Republicans it never will be.

Friday, February 05, 2010

What is that you say? Your PPI doesn’t work?

Well, that’s OK, as you are in a lot of company. First, for those of you who don’t know, and still care to know, a PPI is a Proton Pump Inhibitor, like Prilosec, or Omeprazole (Prilosec), or Prilosec OTC (Prilosec again), or Nexium (Prilosec’s active metabolite), or Prevacid, or well, there’s quite a few of them. They are used for GERD (fancy for heartburn) and ulcers.

You might know that the regular dosing of one of these gems is once a day. You know how many times I see a Take one capsule twice a day dosing on a prescription? Lots. Many many times. Why is that?

These drugs though dosed at once a day intervals do not actually have long half lives. Some are quite short, four or five hours. So why do they last so long? Because they bind to an enzyme irreversibly and it takes a while for the body to come back on board. The drugs bind to ACTIVE receptors, which means that timing is crucial: take an hour before eating, so that the drug can bind to those receptors that are become active for the coming food-fest.

I suspect that for many of the people taking these PPIs on multiple dosing regiments that they could get away with once a day dosing if taken an hour before dinner. Thus saving themselves mucho denaros (or their insurance company, which really is the same thing).

Bon appetit.