You stupid paper card is just that…

Posted by The *Angriest* Pharmacist as Drug Companies, Drug Topics, Education, Laws, PHARMACY SECRETS!, Patient Education, Robbery, Stupid People, True Story

Happy Super Bowl Day! I don’t watch much football. I’m a BASEBALL fan, myself, but I will get drunk and scre eat some wings with my wife.

I know you’ve seen these stupid ass little paper cards floating around in magazines and periodicals. They are laid out like your standard insurance card, and they do a great job at tricking stupid people into thinking they are insurance cards. What I don’t understand is how someone could be so dense as to think that, “I bought a magazine / insurance policy last Tuesday. On Wednesday, I went to the pharmacy and got all my ’scripshuns filled up for free….that insurance I bought for $3.99 was awesome! Celebrex for free? DAAAYYYUUUMMM!” [You now hear and see me beating myself about the head with my stack of bathroom Drug Topics]

I’m now going to drop some serious knowledge on the non-pharmacy people of the world. Pharmacy Secrets numero leche con wavy lays.

- Amphetamine XR 5mg has an AWP** of $100 for 30 capsules
- The true cost to the pharmacy for #30 caps is AT BEST usually around 20% less than AWP. Most of the time, it is closer to 15% these days (the bulleted list below explains that). So, we can paid $80-85 to acquire.
- So the Pharmacy will put in the computer system that we bought the drug for 80. There will also be an AWP field. We put 100 in there. [This is for simplicity. In reality, AWP is calculated by taking the AWP per the number of caps in a stock bottle. So AWP is 138.99 for a 60 count bottle, AWP is input as   2.3165 (138.99/60). Cost is the same way.
- Insurance companies get the claim and, to them, it looks like we are telling them, “Hey, this medicine COST us $100 to fill. We need that to break even.”  -- Well ins companies know how the game is played and they tell us to piss off. They know AWP is set at 20% above our cost. So, they pay accordingly. The most common equation is AWP-10% to AWP-15%. Sometimes, there is a constant put in. For instance, AWP-10%+$3. Whereas, the $3 is considered a dispensing fee. It helps increase profits for pharmacies, but usually means that the percentage is going to be LARGER…
- Going by these methods, we would get paid:   $85 to $90      if using just AWP-10/15%  [+/- $3 depending]. If I make $85 dollars on an $80 prescription, can I afford the pharmacist, technician, computers, utilities, paper, support staff, telephones, and just about a million other costs associated? Absolutely not. How does this work? Ahh…you’re forgetting the COPAY! That….she’s a mine! So, Amphetamine XR is a generic, but it’s a new generic…still made by the BARR, the brand name manufacturer. Hell, even the numbers/symbol on the cap is the freaking same. I’m not sure what the copay would be, but let’s say it’s 25 dollars. That means that I actually made $110 on the $80…which is a gross margin of  27%. That’s pretty good for a pharmacy in 2009. To really stay competitive and continue living, you need to get some 30%+ in there as well….to balance w/ the next bullet:
- $4 prescriptions. So, we are charging $4 absolute to the patient. We can say the AWP=$4 then. The cost is NOT usually 20% less on these…it’s actually MUCH less (WM wouldn’t have thunk it up otherwise). Cost on $4 rxs range from $0.20 to $2.50 for others. Average would be around $1.25. That means that we only make $2.75 per Rx average. While the gross margin appears to be good on this, at 30+%, it’s a TRICK – think economy of scale. It costs just as much to fill this single prescription that is going to net me $2.75 profit while your Amphetamine is going to net me $30. Same amber vial, pharmacist, technician, labeling, etc….and we’re filling a lot more$4 rxs than ever before due to doctors using them to dictate their prescribing habits.
- How does insurance figure in on these? They don’t. While we are required to submit the claim to them, as they track the patient’s utilization of their benefits and ensure compliance for their own records, they don’t pay us a cold damn cent. In fact, it COSTS us a nickel to 15 cents to process the damn claim – like it’s dialing a long distance fucking call…bogus!  The claim submits, and comes back with the cost the same, AWP acknowledge, and third party paid $0.00. But, don’t forget the copayment! Some insurances have flat copays of $8 for generics (even though $4 is less than $8,right? Duh.) So, the patients would most likely say, “Take it off my insurance! Just bill it cash!”  Across the country this is happening for third party claims – private insurances and medicare part D. Now I’m not sure about the private ins claims and a patien’ts contract with them, but I’m 100% positive that it is illegal for a patient enrolled in medicare to not utilize their benefits – even if the benefit may be a detriment at the time. People do this like crazy to avoid “the donut hole” as if $4 is going to get them there with any haste. I don’t fight people on it because I know they’ll never charge someone for evasion, but it is certainly illegal to do this for Part D — and it’s fucking immoral if the patient is on Medicaid. If they have Medicaid and can pay cash, they need to be paying cash and removed from the Medicaid register. Why is this illegal? Because. Because medicare wants to track patient compliance. Medicare wants people to use up their eligibility and MAKE it to the donut hole – then medicare can really start letting the patient have it! I dunno if they make any money, but they certainly LOSE MONEY AT A SLOWER PACE when a patient is eating doughnuts.
-  As a funny aside, Medicare sends these old fogies these printouts of the drugs they’ve gotten, what we billed to medicare, and how much money has been changing hands. I get fucking screamed at for these stupid ass pieces of paper once a week and these dumb printouts say dick and mean even LESS than dick. What they show people is the following.

Pravastatin 40mg Rx#1234567    –    January 27, 2010
What Your Pharmacy Billed to us:   $75.29
What you paid for copays:          +    $3.30
The total of these 2 rows is:         $78.59
^{(the amount we actually paid your pharmacy is $0.00)}

I bet you’re wondering what the infinitely small line of text is:
(the amount we actually paid your pharmacy is $0.00)

What the point in sharing this information with an old person? Not a damn reason one other than to get ‘em all riled up and hope they die of a heart attack before being beaten to death by their pharmacist. All these old people see is that bottom line. Now…why did they add that column? Because that’s what you do with columns…you add the mofos!  They have nothing to do with each other. And that “billed to us” is a joke. That’s the AWP at work…being worthless. Pravastatin is a drug that the AWP has never fallen. We get it for less than 5 bucks per bottle of 100 and the AWP is still hundreds….the insurance companies are well aware of the $4 rxs as well as the COST of each medicine as it’s available to each chain – they know all and see all. They pay nothing.

Now, to finally answer your question – it’s exactly as above….except on every drug. Not just $4.

Some companies negotiate contracts with the drug manufacturers and that’s what dictates their formulary and the costs that the patient pays. For instance Amoxicillin is a $4.00 rx. We bill it to Anthem, they have a contract with us to give them discounts in specific areas. So, the copay comes back to the patient $2.75 cents. Then you look at what the 3^rd party actually paid — $0.00! This is precisely how those free cards work – only w/o the contracts. MY computer system won’t let me fill a prescription w/o at LEAST covering the cost of the medicine (what we paid)  plus 3 dollars. Well, since this Amox is 2.75, we didn’t cover that – no way! Since it’s $4, we’d let it slide, but a 3^rd party wouldn’t. But, it doesn’t say paid under cost. It’s good to go…cause of the contract my pharmacy has with anthem. We give them a discount there and somewhere else, we get a better deal – plus we get them in the store buying Tylenol and sodas and shit.

The freebies cards just manipulate the price down and hope that the pharmacist is a east Georgian Tard Hound. Hopefully, I won’t notice that this medicine cost me $50, the patient is being charged $30, and I was paid $0.00 by the third party….Well, I always notice – my computer system helps me. But, how in the hell does the free card company make money? They are in cahoots, if not MAJORLY owned by the drug companies. Bingo! So, the claim comes through when it’s filled and they know, badabing, we got a sucker. If it doesn’t get deleted after X days, they get a kickback from the drug company for essentially filling a script. The manufacturer still sells the drug to the pharmacy at the same price regardless – their only concern is to get them to buy more and more! Those cards aim to help…and aim to screw over your pharmacy.

ON AVERAGE: Calculating COST from AWP
• For single source innovator drugs: pharmacies purchased the drugs at an estimated discount of 17.2 percent below AWP.
• For all drugs without Federal Upper Limits of Cost (FULs): pharmacies purchased the drugs at an estimated discount of 27.2 percent below AWP.
• For multiple source drugs without FULs: pharmacies purchased the drugs at an estimated discount of 44.2 percent below AWP. A further breakdown of multiple source drugs without FULs showed the estimated discount for innovator multiple source drugs to be 24.4 percent and 54.2 percent for non-innovator multiple source drugs.
• For multiple source drugs with FULs: pharmacies purchased the drugs at an estimated discount of 72.1 percent below AWP.

If you don’t want to read the LONG version (attachments and info I’ve typed above and below this line, go to this link: http://www.volunteer-ehealth.org/frisse/erx/2007/05/prescription-drug-pricing-mac-can-make.html — It provides a hell of a good simplified synopsis of all the different acronyms in pharmacy costs and explains them well. Give it a look either way actually.

Never ask an old bittie her birthday!

Posted by The *Angriest* Pharmacist as Courtesy, Education, GUEST CONTRIBUTOR, Lazy People, Management, Me being a dick, Me hating others, PHARMACY SECRETS!, Patient Education, Rude, Stupid People, Technicians, True Story, Work Sucks

There was a comment made to my last post, SATURDAY’S SUCK! where a guy swore he called and asked me about our having a product. He swore he talked to the male pharmacist. I was the only male working in the store, and we did not talk. My response to the comment turned into a store and then a rant. So, as to not detract from the original post, I’ve taken this comment and my story/response their own post. Hope it doesn’t suck!

We get this all the time…we are a tiny ass pharmacy, i kid you not…we have 2 pharamcists and 2 techs…all week long, same peeps. So when someone says they ’spoke to someone’ it’s very easy to call them out as a liar.

As for your “loud and clear” guy…i totally feel you. We had something very similar happen to us the other day. We just get back from lunch and are opening up when a woman approaches the consultation window where I am at a computer trying to figure out the faxes that came in over lunch. She stares, I greet her cordially and ask her if there’s something I can help her with. She stares and then rolls her eyes and says “No, I just thought i’d come up here and look at you” and then she stares. I blink back at her and glance down at the empty drop off window and empty register and then ask her if she has a specific question about medications (that would require a pharmacist) or if she has a question that I can help her with. She says “Medicines..i’ll talk to him” and points at our pharmacist. He had a student that day so when he had started her on a small task, he went down to offer the woman her consultation. She proceeds to tell him that she needs to know if she has a refill on “some med on her profile” he asks her what she would like him to do specifically, because it’s something that a tech can handle and now she’s interrupted him…she rolls her eyes and tells him to “look it up on the damn computer”

He brings her down to the drop off window and the other tech and I back up about 10 feet. He asks her for her birthday. You know as well as I do that it is the easiest way to look up a patient. She stares at him for a moment and then gives him a month and day. My pharmacist waits for a beat..then asks for a year to which she scoffs and says “every year” my pharmacist waits…and at this point the phone is ringing, there is one on hold, i’m on the 3rd line and the other tech is on the register. So he politely asks for the year once more and the woman flips. Starts yelling at him that he is inconsiderate and can’t take a joke and refuses to help her. My pharmacist calmly tells her “Ma’m, i’m trying to help you, but i don’t exactly know how to respond to you right now, you’re not being very easy to help” so she spouts off that she was just joking and that he shouldn’t need any more information then the month/day of her birthday. So he snarks back “how about your name?” at this point, we back up about 10 more feet.

She finally relented to let him have her name at least and when i was checking her out at the register, it was with a final comment that she should buy us a sign that says “Do Not Joke with Pharmacist…for he has no sense of humor” and then proceeds to tell the other tech that we should spend our breaks and lunchtime out on the floor showing poor people like her where the vitamins are instead of giving them a specific aisle number and shelf.

Just goes to show that apparently no matter what you say or what you do, some people are just that stupid. I’m totally done with everyone looking at me blankly as I remind them that January means reset deductibles and shifted formularies. It’s completely my fault that their insurance probably sent out 10 notifications that they didn’t read

I have an old bitch like this too. All of the FT employees (pharmacist and techs) know who she is on sight. She is the meanest, grumpiest, rudest bitch ever born. We all know that you do not ask her birthday…However, our technicians are BEATEN if they do not acquire the birthday and write it on each prescription as well as verify the birthday upon checkout to verify the correct patient is picking up the medicine. This, for some reason, causes Ms. Bitch considerable problem.

She tries to play the “you should NEVER ask a woman her birthday”, but the problem is, she takes it to a whole new level — a weird, obscene, asinine level of fucked-up-ed-ness. Her reaction and response to the question, “what is your birthday?” is comparable to the response you would receive from other women when asking, “I bet you’ve had miles of dick in you…amiright?” or men when asked, “What were you and your wife doing last night when I was nailing your daughter on your living room couch?” If you get the simile, haha….if not — let’s just say her response/reaction is over the top negative. She is just plain out ugly (in BOTH ways…)

Last time she came in, I approached the counter and you bet your ass I asked her birthday. She gave me the usual, expected attitude — the response I was trying to elicit. I pointed to the sign that every pharmacy has that says, “We verify identity with photo identification for all controlled medications.” I told her that she could either tell me her birthday or show me her driver’s license. She snatched the pen out of my hand and wrote it on the prescription herself — only the month and day mind you — and threw both down on the counter in utter disgust. The pharmacy is completely empty at this point so the big urge for secrecy and confidentiality is unfounded — and by empty I mean REALLY empty…not even OTC shoppers.

She got about 10 feet away and I hollered to her, “I must have the year as well.” –

“You know very well that you do NOT need the year. No one else ever gives me any trouble. They never ask my birthday. Everyone back here knows me — they ALL know me. Ask them. ASK DAVE!”
[If you know me through this blog, you know that referencing DAVE, that old prick that managed the pharmacy before me for 20 years and still works a day or two per week prn is one sure fire way to get on my bad side and ENSURE your script won't be filled...I don't give A FLIPPING FUCK what David used to do for you (most of the time illegally -- based on the letter of the law and MODERN pharmacist code of ethics). I am not him nor do I strive to be him.]

“Dave’s not here. Dave’s not the boss. I’m the boss right now. The rules of this store, and the rules that I am going to follow…the very rules I expect these girls to follow when they take your prescription…is that you MUST give us your complete date of birth upon dropoff.”

DID I MENTION SHE ALWAYS WEARS A MOO-MOO? (and usually has curlers in her hair — or at least a weird showercap/hairnet) I’M NOT EVEN KIDDING. I’M SUPER CEREAL HERE!

“This is ridiculous. I’m calling your superior.”
“Well, then…here’s his business card. I’m sure that I will get in plenty of trouble for following company policy. They fire people all the time for following the rules that ensure patient safety. Why do you take such offense to someone asking your birthday? I mean, we are a part of the healthcare team here and you treat us all like dirt. Do you act so resentful at your doctor’s office when they ask your birthday? I’ve never seen someone yell at their granddaughter before — back when she worked here 5 or 6 years ago — for verifying her grandmother’s birthday (even though she knew it). Did you ever try to eat your young?”
“They may not fire you for following protocol as you call it…” I interjected like a smartass with, “Actually, I called it policy…”
“WHAT – EVER! You have no right. You have no need. You have no access. That is private information that you do not need.”
“Ma’am, you are gravely mistaken. I have a definite need for your birthday — considering some medicines may be contraindicated in certain age groups. That’s for your safety and to ensure the right person is selected in the computer and the right dose is dispensed! In fact, pharmacists have a need and a right to access your complete medical history…and you’re raising cain over your birthday.” [I've revealed TONS of information about readers just by them sending me their email address and name -- I've sent them back their name, address, phone number, map to their house, and a PICTURE of the front of their house in certain cases. You do NOT have privacy in 2010...]

“That’s it…I’ve had it with you…give me the prescription back.” [I, of course, give it right back to her] “I’ve been coming here for 20 years, and David never treated me with such disrespect. I’ll never be back here, and I *will* be calling your employer. May God bless you and let you live a long, but hopefully miserable, life.”

“Aww you’re so nice. May your children place you in the cheapest, roach-ridden nursing home available for the rest of your life.”

She, like all patients continued to come to the pharmacy. She made no effort to change or avoid me. This ordeal was a few months ago, but she suddenly disappeared. I always watch the obituaries, and I was hopeful she’d turn up. But, alas, I discovered she HAD been placed in a home…and YES, it is the most roach-ridden place available in the nearby area!

Who says dreams don’t come true?

Saturdays SUCK

Posted by The *Angriest* Pharmacist as APhA, Disgusting, Drug Topics, Errors, Lazy People, Me being a dick, Me hating others, Money, Patient Education, Politics, Stupid People, TPA, Technicians, True Story, Work Sucks

I’m lucky that I don’t have to work weekends on a consistent basis, but I do get the pleasure of working every 4th Saturday. What sucks about Saturdays? Nearly everything.

- I have to work 11 hours as the lone pharmacist.
- I get no lunch break. I sneak back to our little office and swallow a sandwich whole. I usually get interrupted 2-3 times to check in-store prescriptions or answer an old person’s call — they usually just have refill numbers of course!
- The technicians scheduled are all my part-time HS/College kids — meaning they know the most basic of tasks in the pharmacy and on the computer system. So, I type almost all prescriptions AS WELL AS check them. At least they count, right?
- We run two shifts of techs. They switch out at the lunch hour.
- We don’t do a ton of scripts. Maybe 200 total…250 is pushing it.

My last Saturday that I worked wasn’t super busy, but I was inundated with idiots and assholes — more so than on a regular day! At one point in the early afternoon, a short, fat man approached the counter right after my lunch time shift change.

“Yeah, I called and talked to the pharmacist, and he said you had Carter’s Liver Pills.”
“Well, I’m the pharmacist today — the only pharmacist working here all day. I didn’t take the call. I’m not sure who you talked to. Anyway, I’m not sure what ‘Carter’s Liver Pills’ are. What are they for?”
“They’re for the Liver.” [I guess I had that coming]
“Well, nowadays, there isn’t anything available over-the-counter for ‘the liver,’ and products couldn’t advertise themselves as such. Let me look it up on the internet.”
“Well, I don’t know why the pharmacist would say you had them if you don’t. He said they have them on the shelf!”
“Sir — I’m the only pharmacist on duty, and we did not speak today. Are you sure you called the Angriest Pharmacy?” [Well of course he did! He talked to the pharmacist!] “Well, give me just a second to go check some sources on the internet.”

So, I went to McKesson first to see if I could get it. I often use MCK to ascertain the existence of some of the shit people dream up that their friends, third cousins, and great grandmothers told them about years and years ago. When you search “Carter” on MCK, it returns one result — CARTER’S LITTLE PILLS. I immediately just thought the man was short, fat, and stupid…mistaking / misinterpreting the word LITTLE for LIVER.

I then moved to Google. I searched “Carter’s Liver Pills.” That took me to a OLD message board site that explained the name was “Carter’s Little Liver Pills,” and the word liver was dropped when government involvement required documented efficacy [DESI, anyone?].

Next stop was Wikipedia. This told me that it was heavily advertised BISACODYL even back then. Coincidentally, it is STILL bisacodyl, and it is available….available in MY STORE! Woo hoo! Surely, the short, fat, stupid man would be happy with my research and time invested and would buy the product and be pleased with his poopie pills. But then I woke up….
“Okay. Here’s what I found. Carter’s Liver Pills were renamed to Carter’s LITTLE Pills many years ago due to government or FDA regulations. We actually have those. They are down the stomach aisle as they are just a laxative called Dulcolax. The drug name is Bisacodyl.”
“No. That’s not it. They’re called Carter’s Liver Pills, and I drove all the way up here to get them cause the pharmacist told me you all had them. Apparently, you just don’t want to help me.”    [Why does this always happen to me?]
“I’m not saying you didn’t make a phone call and talk to a pharmacist. I’m simply telling you that you did not call THIS pharmacy nor did you talk to THIS pharmacist. As you can see, I’m working here with these younger technicians — none of them would have answered the question about “Carter’s Liver Pills” without asking me. Girls — did any of you talk to anyone about “Carter’s Liver Pills”? [Of course not] Okay. Anyway. We don’t have Liver Pills. No one has Liver Pills. What I’m telling you is that Carter’s Little Pill is what replace Carter’s Liver Pill.
“Well, you just try telling that to my wife. She’s expecting Liver Pills.”
“And I’ve told you…this is it.”
“Why can’t you just admit you made a mistake?”    [Wait...whaaa??]
“Mistake? Mistake? You’re joking right? What mistake was made here?”
“You don’t have Carter’s Liver Pills.”
“I guess if you want to split hairs, I do not have Liver Pills. I do have the new version called Little Pills. The LIVER pills are no longer made or sold anywhere.”
“Then why did the pharmacist tell me you did?”   [Wow, really?]
“I am the pharmacist. We have never spoken. We have never met….”
“Then where is the guy I talked to?”
“That is a mystery isn’t it. I don’t know if you noticed, but I am the only male employee here today. The rest of these high school girls certainly didn’t impersonate me and tell you that we had the Liver Pills. Did they?”
“Well, it’s all clear as day now. I can hear it LOUD. AND. CLEAR. You are perfect. You’re too god damn good to make a mistake…well, you’re not too good to make one, but you’re certainly too good to admit it! I can hear you LOUD AND CLEAR! I can’t believe I drove all the way into town and I’m going home with nothing! Who’s gonna pay for my gas money? I drove 8 miles!”
“I’m sorry that you are at a disadvantage here. If I had made a mistake, somehow,  I would have admitted it….but, I haven’t made one. You are just angry for some odd reason. If you’d like, I could call your wife and explain to her the product’s new name — and that it’s the same thing.  Or, if you’d like, I could take a sharpie and cross out the word LITTLE and replace it with LIVER!”
“This is exactly why I don’t get my prescriptions filled here. You all are the worst kind of people.”
“It’s probably best that you don’t fill them here. If you did, I’d refuse you service from this point forward.”

As he said, “LOUD AND CLEAR” — both times — he pointed to his left ear, where he had a HUGE hearing aid. So, the man was partially deaf. He must have MISHEARD the pharmacist he talked to on the phone! [Which wasn't me]  The last line, where I said I’d refuse him service, was said as he was walking away. It’s pretty unlikely that he heard me…so, while I’m a wussy for whispering, I meant it!

Anyway, that’s the story of my run in with the short, fat, stupid, and DEAF man dwarfish asshole.

PS — Kudos to the DrugMonkey for a KICKASS article on the suckiness of Pharmacy organizations. Wonderfully pithy, well-worded, and a resounding YES to the question of, “does drug topics have the guts to let its contributors / authors publish the cold, hard truth?”

http://tinyurl.com/DrugMonkey

My “Why APhA Sucks” article from Dec 2008 pales in comparison.

Another DrugMonkey jab at APhA

Diagnosed — A Case-Based Post

Posted by The *Angriest* Pharmacist as Doctors, Education, Patient Education, Results, True Story

Older lady (50-something) calls in today….really…today January 13, 2010.

“I have a pretty bad stomach ache. I’ve tried everything.”

After a lengthy discussion with a lady that was pretty sharp when it came to OTC meds and taking care of herself, here were the facts:

- Epigastric pain above the belly button, beneath the sternum.
- Rarely radiated. Sometimes pulsated. Sometimes had back pain, but figured it was due to her job as a cashier.
- Patient has (un)controlled hypertension. Her BP is high, but she is finally under treatment after years and years of uncontrolled HTN. It’s on the way down, but not to goal yet.
- Has tried the following meds: Rolaids, Gaviscon, Milk of Magnesia, Fibercon, Colace, Zantac/Pepcid, Omeprazole, Protonix, and Tylenol/Ibuprofen (after thinking it could be muscular).
- Worsened over time.

So, short list of facts. Very busy pharmacy. As a pharmacist, we’ve really gone as far as we can go with our expertise — as far as what we can suggest. What do you think the patient has? What do you tell her to do?

The answer is below.

I told the patient she had let this problem linger for far too long. She needed to go to the doctor and be seen. I told her to “mention the pharmacist wondering about a ‘triple A’ to her physician. Some doctor’s might call it an A-A-A.”

I told the lady at the time that this was a crazy idea, probably not even on the radar, and the doctor would probably laugh, but it was something to think about on the list of possibilities. I then explained it to her — what an abdominal aortic aneurysm was — and she was obviously scared which made me feel like a douche. I told her how rare they were and not to worry about it.

Later this evening I get a FAX from her primary care physician with her admission face sheet and the following handwritten:

HOW DOES A PHARMACIST DIAGNOSE AN A.A.A. OVER THE PHONE?

– If she survives the surgery, we can say you saved her life…(well, you and the vascular surgeon)

Lucky Guess…I know…because I didn’t even know her name when we spoke on the phone — I didn’t ask. We do fill her medicines, and I recognized her name when I saw the fax. I even know her face…I will update on her status tomorrow if I find out.

=========UPDATE=========