A pharmacist's look at the supermarket and beyond

Category: medicine (page 1 of 7)

Metrics? We Don’t Need Stinking Metrics!

We all know that retail pharmacy or health care in general can be a difficult and often thankless job. I received this letter in the mail and it made me happy!
grateful letter
The gratitude was well received by myself and staff. Eventually I began to think about metrics. Pharmacists and techs spend hours every day dealing with undecipherable prescriptions, impossible billing, and a wide assortment of barriers to good pharmacy care. As pharmacists we dole out free advice on a regular basis to patients that are usually appreciative. Patients will talk to us about anything.
On the same day that I received this letter, I had a man in his 40’s wondering why his doctor ordered Prozac for him when he was not depressed, just dissatisfied with the quality, quantity, and duration of his erections. He broached the subject and responded to one of my counseling questions by saying, “I think I’d be OK with a group of half naked cheerleaders.” That’s when the conversation moved to a more discreet level.
Later, a student pharmacist asked for my assistance counseling a young woman who wanted help selecting a prenatal vitamin. Turns out she was trying to get pregnant, and after explaining the benefits of a prenatal product and other healthy options, she took the conversation to a deeper level. After discussing underwear choices for her husband, she volunteered information about her tipped uterus and asked, “are there any positions that might compensate for that?” I was tempted to tell her the joke about positional gender selection, but my professionalism vetoed that idea. In case you are wondering, missionary and girl on top are the top two recommendations.

All three of these interactions are wonderful and meaningful experiences for the people involved. They do not, however, have an effect on our metrics, which, increasingly, is how our job performance is measured. We are constantly bombarded with data that is presented as helpful information to make the job easier as we gain effectiveness. Yet our “Percent Effective” measure looks only at the labor hours (and minutes) gained for the tasks that are required to fill prescriptions. The bottom line is that the biggest chunk of data demands that we fill a prescription using about 8 minutes of labor. And, there is time built into that to allow for counseling, regulatory compliance, inventory control etc., but at the end of the day it’s how many Rxs were filled with the labor permitted.

You can easily see that the scenario that Jay describes in the letter would have taken much more than 8 minutes to complete. Multiple people were involved and it required several faxes and two phone calls to the prescriber, calls to the patient, and multiple attempts to successfully bill the claim for the product. The forty-something with problems “down there” and I had a ten minute conversation exploring possible causes and solutions for his dilemma, which included the recommendation that he should keep his lust for cheerleaders as a fantasy. The young mother-to-be was another lengthy discussion that started out looking at vitamins and evolved into a frank discussion of the physiology of fertility.

All three of these examples had great outcomes and yet only one prescription was picked up by the patient, the testing strips for Jay. The other guy did not get the Prozac prescription, effectively making all the labor to fill it wasted, and created more labor to return it to stock. The soon-to-be-mom bought a prenatal supplement and left with several helpful ideas for conception strategies. In my judgement, all three of these were big wins for myself, my staff that were involved, and the student pharmacist that gained perspective on the delivery of very personal, even intimate counseling.

If we are lucky the patients will do one of those ubiquitous satisfaction surveys and we will get a second of recognition that way. Our metrics will suffer though, and that is a price that I am willing to pay. My patients know that they are not numbers to me. My whole team works hard to establish a solid rapport with each patient and from that grows the trust and mutual respect that lets our pharmacy thrive despite intense competition.

Metrics are a tool, a limited tool that will never be able to measure the kind of outcomes that health care providers work for every day. Labor hours should be added to the metrics algorithm that would allow us the time to treat all of our patients the way they deserve. Wouldn’t the loyalty and improved health and happiness of our patients be worth a couple hours of labor per week? After all we give ’em $25 just to transfer a prescription to us from a competitor. We should be playing the long game.

A Prescription Gone Wrong

The national media and social media exploded a local story of a pharmacist refusing to fill an prescription for misoprostol for a woman carrying a dead fetus. It’s difficult to get the exact details of the whole process, which took place over several days, but I think some of the events are evident and worth discussion.

Let’s first be clear that we should not have this opportunity to discuss this specific situation. It should have been a private process involving prescriber, patient and pharmacist, as we expect for each prescription filled. This patient, however, chose to put her uncomfortable and personal experience on social media, Facebook, and from there it migrated to more traditional local and national media. OK, that is your choice. So now anybody who cares to voice an opinion is free to do so and I will take my turn.

The OB/GYN ordered an effective drug that would terminate this nonviable pregnancy. A miscarriage was inevitable and the drug would allow the patient’s medical team to control the process. The prescription was taken to a Walgreens where the pharmacist would not fill the prescription for reasons of strong personal beliefs. The patient attempted to explain the medical reason behind the prescription and the pharmacist was unyielding. Apparently there was significant back and forth discussion between the two with that patient’s 7-year-old child, other pharmacy staff, and other people standing in line listening.

This is where things go careening off the tracks. First, the pharmacist should have recognized the very personal nature of this exchange and taken the patient to a discrete location for a private consultation. Most pharmacies have a consultation room and if not can find a private space. Retail pharmacies prominently display a large HIPAA sign that explain patient privacy protections. The dilemma for retail pharmacies is that the area where patients pick up their prescriptions is not private. Oh, we may have a little plastic divider shield, but if you look at most retail pharmacies there is little barrier between the pharmacist and patient at the counter and the patients waiting in line to be next or even in the waiting area. Do patients in this situation implicitly give up their privacy rights simply by being there willingly? To me, this particular situation was handled poorly by the pharmacist and the patient, but the pharmacist, as the professional, failed to act professionally in respect to patient privacy. Yes, the patient chose to discuss the details in this setting and then further on social media. At the pharmacy counter, however, the pharmacy staff should realize the obligation for discretion and act upon it. I have asked hundreds of patients to join me in our consultation room or another private space to discuss sensitive issues. Most pharmacists I know would do the same.

The moral objection to filling a prescription is supported in most pharmacy organizations and each of them that I have seen advise the pharmacist to provide another means for the patient to acquire the medication. This did eventually happen and there is some disagreement as to why it took from Thursday to Saturday for the Rx to be filled and picked up. One side claims that there were other pharmacists in the pharmacy the day the Rx was first presented and they were not asked if they would fill the prescription, while others say that the pharmacist did transfer the Rx to another Walgreens that would fill the Rx and it was the patient that delayed picking it up. Some of the latter have claimed that on Friday the patient was too busy giving interviews to TV news outlets and playing the victim card. Perhaps there is some truth to both sides. I will let the Arizona State Board Of Pharmacy complete their investigation and trust they will come closer to the truth better than any individual possibly might.

Pharmacists are presented with medical dilemmas every day. I have refused to fill many prescriptions. Some of those have been fraudulent, some have been presented by obvious drug seekers using multiple doctors or other schemes, and others were instances where I considered the health and safety of the patient in jeopardy. I personally believe that is the scope of our practice. We should fill all legitimate prescriptions unless the physical or mental health or safety of the patient would be put at risk. I do not believe that we should be making religious or moral judgements when assessing the appropriateness of a particular drug for a particular patient.

This particular drug had been identified in the pharmacist’s mind as a drug used for inducing an abortion and therefore would not dispense it. Any other use of the drug was apparently disregarded. I believe we are scientists, not priests. There are plenty of opportunities for pharmacists to apply religious or moral judgment on patients based on the prescriptions that they ask us to fill. Is this birth control Rx for a 16-year-old appropriate? Is that too young for sex? Is it better to provide contraception rather than risk a future abortion if she is sexually active? Oh wait, those questions are moot because the patient is taking the medication to control disfiguring acne, or to lessen her disabling dysmenorrhea. Do you refuse to fill HIV drugs because you consider HIV the “gay plague” and God intends gay people to suffer the consequences of their “choice?” Is it right for a pharmacist to work in an establishment that sells tobacco, liquor and sex toys? Each of us must decide our own morality, and we are free to express our opinions, but we have no right to impose them on others.

Forget These Products

An elderly lady was at the pharmacy window picking up prescriptions and needed help finding a OTC product. She had been taking something for memory, but could not remember its name. If it wasn’t so sad, it would be funny. The culprit here was Prevagen and I was able to point her in a more reasonable direction. This was made easier by the exorbitant price of Prevagen.

I recently asked a student pharmacist, Thuy “Tina” Ngan Vo, to look into some of the “brain boosting” products that we offer. Although I have posted about Prevagen previously, I felt that her research added new facets to the discussion and bolstered the argument against spending money on these products. I was especially pleased to see Tina take a close look at the “clinical studies” used to market these expensive products. Her original paper is on this site, but I’d like to put my two cents in also.

I’ve already called out Prevagen as snake oil and not worth a dime, let alone more than a buck a pill. The only study that purportedly showed any action at all showed that apoaequorin (active ingredient in Prevagen) infused directly to rat brains may have slowed ischemic cell death. The study was totally funded by the manufacturer, not peer reviewed and the claims of memory enhancement are total bullshit. Though the manufacturer cites many clinical trials, actual peer reviewed trials are non-existent. So, to be clear, when you take a Prevagen pill, any apoaequorin present (if any) will be destroyed by your digestive tract, you may get a peptide or two or some amino acids, but the rest will be tomorrow’s poop. Shame on Quincy Bioscience.

Maybe the patient should try Natrol’s Cognium, that sounds pretty science-y, right? Here we find silk protein hydrolysate. Wow! That sounds impressive! But, digging a little deeper we find more bad science, and in this case a set of six trials by the same author. One published manuscript was retracted due to data fabrication and falsification by the authors. Even the best of these “studies” claims a meager 1.7% improvement in cognition. Save your money!

So maybe one the many herbal supplements would be a good choice. Have a look at Healthy Brain All-Day Focus. This has some vitamins, ginkgo, some roots and other crap (see Tina’s paper) none of which, if present, will help. One ingredient, Rhodiola Rosea root was shown in one study on intern nurses on shift work to actually worsen fatigue! Stop wasting your money! Don’t have a brain fart!

So what can this patient do to help sustain and possibly improve her memory and brain function? As Tina points out, higher homocysteine levels have been associated with Alzheimer’s as well as an increased risk of heart attacks and strokes. Homocysteine is an amino acid that is a by product of protein digestion, particularly methionine, which most of us consume as animal protein. I would suggest this patient start with a reputable B-complex vitamin supplement, with good representation of vitamins B-9 (folic acid), B-6, and B-12, just in case her diet is lacking in these vitamins which help to detoxify homocysteine.

Notice that I said “reputable.” These products are unregulated and what is stated on the label may not truly represent the contents. I look for the US Pharmacopeia symbol to be sure that we have a product that meets scientific standards.

Beyond a good B-Complex supplement, I also recommend:
Try new things that require learning. Make it real, the FTC warns that these brain game apps overstate their usefulness. Working a crossword or finishing a puzzle is good but learning new things is even better.
Be physical. Stay active. Walking is the easiest and requires no special equipment. Swim.
Avoid nicotine. Limit consumption of caffeine and alcohol.
Maintain a healthy blood pressure to avoid strain on your cardiovascular system and avoid accelerated organ damage and strokes.
Besides, ginkgo, there is no proof that vitamin E, ginseng, or mass quantities of fish oil are of much benefit.
Modify your diet to eliminate as many processed foods as possible and limit your consumption of animal protein other than fish. Although there is that worrisome connection between methionine and homocysteine, we do need methionine (it is an essential amino acid) so do not try to completely eliminate if from your diet. Moderation is key.
Socialize to improve your mood and engagement. Love your loved ones and live and act for others when you can.

Not a Scary Movie

He was always willing to help out, covering an extra shift here and there, offering to work till closing alone, and always just so darn helpful. It wasn’t long before I began to notice the dark side, however. The nervous reaction when a pharmacist or tech approached him while he was working alone, escalating offers that would allow him to be alone in the pharmacy, and an underlying sense of dishonesty, all led to suspicions of misbehavior. Then product started disappearing. When alerting management of my suspicions,I was advised not to schedule this pharmacist for coverage shifts any longer, effectively terminating his part-time employment with us. I know now that this was the wrong thing to do. He was never allowed back in that pharmacy.

Months later he started showing up at the clinic and the pharmacy. He brought treats for the nurses and the pharmacy staff. He tried so hard to ingratiate himself into our good graces. I could still see the dark side, however. The offers to send myself or the staff pharmacist home early and he would close up for us, resumed. Even off the clock! I detected the furtive glances trying to see how much hydrocodone we had on the shelf. I could feel the desperation.

Despite what management had told me, I felt that I must intervene, so I took this young pharmacist to my office and discussed his obvious substance problem. At first he denied it all, of course, but as I expressed empathy and pointed out the obvious addictive behaviors, he told me the whole story. Like many patients with substance abuse disorders, it began with a legitimate prescription for pain management of an acute injury. This pharmacist had be in a grievous accident, involving multiple fractures and significant pain. The slippery slope was too much for him to overcome. In a familiar progression of events, he started augmenting his regular prescriptions with Rxs from other prescribers, taking a tablet or two during his works shifts at one of his three part-time jobs, to eventually stealing entire stock bottles as his addiction took control of his life.

Fortunately, he was able to break the cycle of addiction and get the help he needed. He admitted his addiction to his parents and referred himself to the board of pharmacy and into the PAPA program. All of this happened over a decade ago and that pharmacist is now rehabilitated and working in the profession.

Over the years I have had more opportunities to see the scope of this problem. It has many different faces. A doctor friend whom I played racquetball with on a regular basis, had been ordering a hydrocodone cough syrup at increasing frequency from our pharmacy “for office use,” a former student was caught on tape accessing the narcotic cabinet during non-business hours and removing product, I was asked to go to a pharmacy as quickly as possible because there would be no pharmacist there and arrived in time to see the pharmacist being “perp walked” out of the facility, I was nearly physically assaulted when a call from a technician required me to go and ask the pharmacist for his keys and terminate his employment as he was obviously drunk, and belligerent, on duty. The scary stories are endless.

Most of us enjoy the thrills we get from a scary movie, whether it be an evil clown peeking out of a sewer or mysterious creatures from an upside-down world right next to ours. In real life, not only our patients are affected, the problems of substance abuse permeate our profession. Pharmacists are not unlike our patients and have substance abuse disorders at about the same rate as the general population, somewhere around 12%. The problem is scary and all too real.

This is why I became a part of the Arizona Pharmacy Foundation which provides critical support for the PAPA program as well as providing education for pharmacists and the community to prevent, recognize and understand treatments of substance abuse disorders. It’s rewarding to be a small part of an effective solution.

Va Va Land

There are some pretty nifty developments in the realm of women’s health. We have come a long way from the days when I had the rather unique opportunity to learn how to install an IUD. Not too many pharmacists get an opportunity like that! Over a decade ago, as Pharmacy Director at ASU Campus Health, our wonderful Ortho rep set up a training class on-site and I was invited to attend along with several doctors and nurse practitioners. We sat in front of life-sized pelvic models similar to one seen here and did not have benefit of ultrasound or other technology, so using just sight and touch, used a small device to carefully place the Paragard IUD. On our models, there was a little trap door in place of pubic hair that we could lift open to see if we had properly placed the IUD. A training session that I will never forget! Yes, I got right the first time! I still have my stunningly stylish Paragard tie tack!

Speaking of vaginas, I came across a bit of trivia. The Walt Disney company is credited with releasing the first film to use the word vagina! Apparently working with funding from Kotex, the animators got to work on explaining menstruation. A ten minute restoration of this animated classic can be seen here on YouTube. I do find it hard to believe that the scary STD films they showed to our boys heading off for WWII didn’t mention vaginas, but maybe not.

Fast forward to modern times and we find that researchers at Northwestern Medicine have developed a miniature, functioning version of the female reproductive system. It is a small cube that can fit on the palm of you hand. This 3-D model is made with human tissue and uses artificial “blood” to allow transport of hormones and other secretions throughout the system. This technology, EVATAR, will enable the testing of new drugs without risk to patients. Imagine having a drug tested on this model, made from YOUR tissue! Ultimately the long term goal is a “body on a chip” which would use your stem cells to create tiny models for testing of various treatments for highly personalized therapies. You can take a few minutes to learn more about EVATAR here on YouTube. Someday, your doctor will harvest some of your stem cells, grow out a heart, a lung, liver, or an ovary and then test dozens of drugs and doses to see which best would treat whatever ails you. Creating a pancreas via this process may someday lead to a cure for diabetes! There is a male version on the way called ADATAR and another focused on the testicles and prostate with the working name Dude Kube.

In the meantime, as we see more and more young people opting for more natural food and drink, it is no surprise that modern women are looking for alternatives to the mass-produced, artificial menstruation products. Many women rightfully worry about exposure to bleaches and pesticides. Several new products are being marketed with moderate success, from natural sea sponges to reusable fiber products like “Glad Rags” or Thinx panties. There are also menstrual cups like the Soft Cup or the Diva cup (these cups may be referred to as catamenia cups in some literature – from the Greek, cat (pussy) -menia (blood) sorry, just kidding, although catamenia is a real word). From what I have read they require a short learning curve as well as the ability to become more intimate with your monthly visitor as well as your vag. If you want to read about one woman’s journey of discovery as she “test drives” these products visit Rachel Krantz. Considering that one woman can have about 450 periods in a lifetime and may use 16,000 tampons, pads, liners and such, its obvious that this is a big market not to mention more “stuff” in our landfills. Having reusable options seems like a good idea to me.

In world news, in Italy, the parliament is debating a measure that would have employers offer “menstrual leave” of up to 3 days per month for women with painful periods. Italy would follow in the footsteps of countries like Japan and Indonesia already offering some form of menstrual time off. It seems like a sticky wicket to me.

More world news. In a response to Donald Trump’s pussy grabbing quote, the Russian girl Punk Band, Pussy Riot, released the English language version of “Straight Outta Vagina,” which reminds us, “Don’t play stupid, don’t play dumb, vagina’s where you’re really from.” These ladies spent 16 months in a Russian jail so they definitely have street cred as fearless feminists.

And now: If your vag feels or looks a little worn out, and needs a little rejuvenation, and you can afford the procedure, and several days off work, you might consider an “Aussie makeover.” It’s suggested for a well-used or stretched out vag, or if it doesn’t match up to partner’s penis size. You can even have your labial lips sculpted! I would never have known about this, but I have the tendency to read anything I can get my hands on, especially in a waiting room.

That’s all for now, my final word is, support Planned Parenthood!

Tour de Cure

I rode in my second Tour de Cure bicycle ride last week with over a thousand local riders, including many colleagues from pharmacy. I raised over $300 which might cover the cost of a box of insulin pens for one patient and that might last a month or more. Diabetes is an expensive disease. I signed up to ride 25 miles but the final course was just over 28 miles. That’s one mile for every million Americans with type two diabetes. Diabetes is a prevalent disease. The Tour de Cure raises money to aid diabetes research. We can only hope that we find a cure soon.

I fervently hope that a cure, when found, is not suppressed. It costs Americans, all of us, either directly or indirectly, about $200 billion per year to treat diabetes. You can bet the medical-industrial complex does not want to see that money dwindle away. I’ve been hearing rumors about this sort of thing ever since pharmacy school, so many years ago. Rumors of drugs that were so effective that they essentially fixed the problem, but the company owning the rights would manipulate the molecule so as to cripple its effect or limit its effectiveness, thereby requiring repeated dosing to hold the problem or condition at bay.
It’s our new business model, after all. We are encouraged, or forced, to “subscribe” to so many of our modern conveniences, lease our cars and gadgets, and constantly renew our prescriptions. Let’s not allow this to happen with diabetes or any other of the diseases or conditions that we all walk for, run for, bike for, or otherwise donate our time, energy and money. I dream that part of our ideal national health care policy is to be sure that basic research, funded by tax dollars or donations, reveals all results to we the people. I know, naive and I didn’t really intend to stray down that path of negativity.

As I pedaled those miles, I took time to ponder some other facets of diabetes, beyond the staggering cost of treatment. There is lost productivity, as well, of course, but it seems that few of the players devote serious energies to managing type two diabetes without coming to me for drugs. Take a pill! If my corporate overlords allowed it, I could spend more time with these patients. Being in a supermarket presents a tremendous opportunity to do some coaching on buying habits and encourage smarter choices. We would spend most of outr time going around the perimeter of the market, limiting exposure to the center which is mostly stocked with processed foods. It does not have to be myself or even one of my staff pharmacists, I’d love to see an appointment system set up to have our at risk patients go shopping with an expert in nutrition. Unfortunately, without a significant charge to the patient, there is no return on investment. In fact, if some of these folks got healthier, we might fill fewer prescriptions. Ye gods, NO!

The baby step here is for patients and their loved ones to start small, by adding some fresh produce to every day’s menu, eliminating soda, whether sugary or artificially sweetened, and slowly sneaking in some exercise. It could happen. It might start with a friendly nudge.

To learn more about diabetes, you must start at the American Diabetes Association! Check it out! I invite you to ride with me next year.

Here is part of our pharmacy fridge. Probably close to $50 grand in there at the moment and that replenishes about once a week.

My Tour de Cure 2017:

My Tour de Cure

Health Care Extremism

The latest attempt to repeal and replace “Obamacare” has failed, despite a Republican controlled Congress and a president that ran as a Republican, but is demonstrably a party of one. The Ryan plan, dubbed the American Health Care Plan, remained too socialist and liberal for the conservatives, too generous to the wealthy for the Democrats, and too weak to be a meaningful replacement for the more robust ACA. I’m glad it failed. It was an extreme and poorly crafted alternative. This is the best they could come up with in seven friggin’ years??!! And then they were willing to bend over for the “Freedom” Caucus and demolish women’s health care. Spineless tools.

Not that I am all that happy with the ACA. Most folks agree that certain aspects of Obamacare are winners,the pre-existing condition requirement, the age 26 coverage as a dependent, and the expansion of Medicaid, seem to be the top three. Major mis-steps are the pricing structure that allows healthy individuals to forego coverage unless they pay a penalty, and the mandated coverage of certain items that are not universally needed. Either way, a person starting out in the workforce has a new expense that will delay many desirable milestones as a contributing citizen. It makes it more difficult to buy that first home, start a family or own a business, and erodes any attempt to plan for the future. Insurers were left offering policies with unneeded coverage line items that inflated premiums and made plans unattractive to potential buyers. That whole pricing/minimum coverage strategy coupled with tax implications are the biggest flaws of the ACA.

My question is: Why must we repeal and replace the entire Act? That’s extreme! Shouldn’t we be gathering our experts and stakeholders to work with Congress and find a workable solution? Congress should be representing the best interests of its constituencies, not special interests such as Big Pharma, behemoth insurance companies and their CEOs, or other members of the oligarchy.

Medicare has worked relatively well for decades. This despite the government “borrowing” all of the money that we have paid into the trust fund itself. The funding strategy is not as convoluted as the ACA and with proper changes in design, intelligent limits on coverage, and aggressive fraud deterrence, a national health care plan is possible. We should cover every American with a basic level of coverage starting with first breath. A balanced fee structure could be designed using a person’s age and income (ability to pay) to determine a reasonable premium. Note that I said basic coverage, you can read that as catastrophic coverage if you like. The main point is to provide federal coverage for all. Once we agree on that we can start to discuss incentives for healthy behavior and limits to care for self-inflicted conditions. We can balance payments according to age and ability to pay. We could even consider levels of coverage above the basic as people entered the workforce while creating incentives for people to seek gainful employment. States could take action to help those at greater risk and lower abilities. I’d still like to see everyone contribute to match their abilities.

This would not mean the end of more robust plans, which could be offered by employers as part of an attractive benefit package. HSAs could easily survive.Once the baseline coverage foundation is established, building on it in the marketplace, either through private purchase or as part of a group (be it employer or other groups), can fulfill that burning Republican desire for capitalism in health care. Although we need to be very careful how this is crafted.

I wonder if we see this extreme behavior to completely destroy Obamacare as a reactionary dislike for our first Black president simply because he is Black. I’ve told my Senators and Representatives that I want the ACA made better, not destroyed. That is how we made America great, by building on our successes and revising and improving on ideas that didn’t meet expectations. Not by the extreme politics that we are seeing now.

And while we are at it: One of the components of the ACA was to limit health insurance executives to $500,000 in tax deductions. HHS Secretary, Tom Price stated that it is unAmerican to single out these individuals.
I agree! Why not have that $500,000 limit on everyone? We could exclude charitable donations to true charities (NOT PACs!). No one is singled out. Problem solved!
Who the Hell needs more than half a million in tax deductions??? Yeah, I can think of one guy too.

Finally, no matter what we do, the end result should be something that can be easily understood by the average Joe. No more of the coverage gap, you pay this % we pay that %, Big Pharma gives you a discount (wink, wink), spend this much, we match, check out of pocket, cover this today, not tomorrow, authoritarian health rules. I must be able to explain coverage to my patients! Preferably in two sentences! That would be Great!

Suggested Executive Orders for DJT

I thought I should expand on a brief note that I have sent to the White House and posted on Facebook. Maybe, though, rather than expand it, I would be better off trying to get it down to tweet size! (Added text in italics)

President Trump,
I am not a lobbyist. I am a practicing pharmacist with a few suggestions for my professional arena that I think will help make America greater.
1. Immediately make all pharmaceutical manufacturer’s discount cards eligible to be used by patients with Medicare. This exclusion is just a lobbyist-fueled, mean-spirited obstacle for those patients most in need of our help with exorbitant drug costs. This is an apparent attempt to avoid violating the Medicare Anti Kickback statute. Congress enacted the Anti Kickback Statute as Amendments to the Social Security Act in 1972. It was more recently revised in 2010 as part of ACA. In pharmacy, one notable case involved Walgreens in a 2012 settlement of $7.9 million. Walgreens, of course, denied any fault. They had simply offered gift cards Medicare and Medicaid beneficiaries in exchange for transferring their prescriptions to Walgreens. I suppose this is similar in concept to a drug company offering to reduce a copay for a Medicare patient’s brand name med. The difference is that patients are given an Rx for a specific drug. It’s not like they can simply go across the street to a competitor. Too often, a patient struggles, trying to decide where the money will come from to pay for their fancy post-op blood thinner or the latest and greatest diabetes med that may lower their A1C by half a point. It’s OK if you are privately insured though! This distinction helps to contribute to the high cost of brand name medications and should be modified as soon as possible. Easily remedied with an executive order! Notice these cards not only exempt Medicare patients but also our veterans covered by TriCare or other DOD plans!

2. Create a third category of pharmaceuticals that could be ordered by pharmacists for the benefit of their patients. Drugs to be included in this category can be selected by a small pro-tem committee of a practicing pharmacist, an academic pharmacist, a physician, a representative of PHRMA, and a consumer. This idea has been in various stages of discussion for as long as I can remember. There seems to be a concerted among powerful lobbying groups to prevent it from ever happening. As always, the reason is money. I’m sure the AMA sees it as an attack on their rice bowl as does the insurance industry. As a colleague of mine pointed out (thanks, Andrea!) Big Pharma should be with us on this after seeing what pharmacy has done to increase sales of immunizations. Easily remedied with an executive order!

3. Immediately grant pharmacists provider status. Congress has dithered with this long enough. Make it so. The latest iteration is a proposed statute granting provider status in rural, under-served areas ONLY. That’s a bunch of crap. The value of pharmacists in the delivery of health care and the resulting improvement in outcomes and cost and been well documented many times. Easily remedied with an executive order!

I tried to keep this message brief and would be happy to discuss or answer any questions that you may have.

Let’s make pharmacy greater!

End of Year Hijinks

The end of the year is always an interesting time in the pharmacy. Some patients are trying to hold off until the next calendar year when they will be out of the coverage gap while others are trying to squeeze in every refill possible because they are beyond the gap or their insurance is changing or co-pays are going up next year.The ones that are trying to hold off are a particular challenge because they often put their health at risk by skipping doses or even entire weeks of medication. We strive to find solutions for these folks, but I fear that much of this behavior flies under the radar and we simply don’t know it is happening. We use partial fills when possible and try to find manufacturers’ discount cards for the more expensive brand name drugs. (see several previous blog posts) Unfortunately, our tool of a Congress has made it illegal to offer these discounts to people that are Medicare eligible. Not even enrolled patients, mind you, “eligible” patients. So even if you opted out of coverage you still cannot take advantage of these discounts! Our Senators and Representatives have no such restrictions, of course, enjoying the best health care coverage possible, on our dime.

So, yes, we have found some of our patients reducing their insulin dosage or simply doing without. Scary. Others forego blood pressure drugs, or even heart meds. It is quite common for people to use a variety of ill-conceived strategies to stretch their supply of medication. Their interactions with their insurance companies must be quite interesting.

One of our patients was recently approved for Enbrel and since he was past the coverage gap and into “catastrophic” coverage his co-pay was only $200. This persuasive and persistent patient was able to convince his Medicare part D plan that he was going on vacation in early January and got approved for a “vacation override” for another 4 weeks of Enbrel. Score! Most patients are not so lucky, each claim that we try to squeeze in before the end of the year is often rejected with a “refill too soon” message that indicates the date it may be filled. There is no easy way around this.

Another patient, with a Health Savings Account (HSA) thought it would be clever to refill all his inhalers, nasal sprays, and anything dispensed in its original container so that he could charge it to his HSA and then return them all for cash. Dude, that’s genius! Luckily, he asked about our return policy before actually proceeding with this scam. Federal law does not allow returns of medication, regardless of packaging, nor would we participate in this attempt at fraud. Dude, you’re busted!

Most of our chronic pain patients understand our guidelines and will not even ask about early fills. We did get a few however who questioned our calendar math, trying to get a fresh supply of oxycodone before the New Year. We are merciless and will not fill schedule 2 Rxs until there is 90% utilization of the previous Rx from the date picked up (not date filled, that may differ). We only had a handful that tried to push the issue. Being closed on Christmas and New Year’s day we often had to point out that even if Christmas was day 27 of 30 (90%), on the day after they should still have 2 days of medication remaining. Patients that continue press this issue end up with us taking a closer look at their utilization over a longer span of time than one month. We cannot be too careful when close to 100 people per day are dying from opioid overdose! Patient education and counseling becomes critical in these situations.

There are also a number of patients that have prescriptions that can be filled before the end of the year that will wait in our “ready” bins until the new year because the patients do not have the funds to pay their co-pays. This gives them about two weeks to come and pick up their meds.

I write this on New Year’s eve and I will tell you that next week will be even more fun as we deal with huge (or is that “yuge” now?) numbers of our patients having new insurance coverage and a fair number of them with no new insurance card, or changes in coverage and co-pays that they did not expect. It is one of the most challenging weeks in a retail pharmacy. Believe me!

Here is a chart from Kaiser that illustrates 2017 Medicare part D coverage:

Mind Games

Here’s a little mental exercise to play with:

We do a huge part of our prescription business in mental health medications. Some of these brand name meds are quite expensive and I would like to focus on aripiprazole, aka Abilify, for this thought experiment. Abilify is indicated as an adjunct or “add-on” therapy in the treatment of depression. There are a couple studies showing that it is more effective than placebo when added to existing SSRI, such as Zoloft or Paxil) or other therapies such as bupropion. Patients report both success stories and miserable failures when taking Abilify. Half of the package insert is a discussion of side effects and adverse reactions. In my opinion this is a drug of some moderate usefulness, high cost, and very significant risks.

One of the state behavioral health plans covers Abilify, and interestingly insists on brand name. I can only assume that some sort of rebate to the plan is in place. Otherwise, why spend more of the taxpayers’ money than is necessary? The monthly cost of Abilify is about $1,000 per month. Abilify is often used to boost the therapy of a depressed patient. So I postulate: If we have a depressed patient, being treated with moderate success with one or two generic agents, and we are considering adding Abilify, why wouldn’t we consider another choice? I would suggest that the taxpayers could be well-served by simply giving the patient $500 cash each month! If I were moderately depressed and on a state welfare plan, $500 per month might be a huge factor in changing my life and lifting my depression. An extra $500, with continued counseling, could change my life in ways far beyond the power of a pill like Abilify. I doubt the plan is getting a 50% rebate, so $500 likely saves the taxpayers plenty of money. Even if the stipend was $300, there would be a noticeable and positive on that patient’s life and lowered taxpayer cost.

I, for one, would rather see my cost reduced and my taxes dollars be used in more insightful and innovative ways. Obviously this is just the nugget of an idea and needs refinement but don’t be afraid to consider this kind of out of the box thinking when it comes to recreating health care.

Think about it.

the wall

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