Pharmacy Optimization With Enterprise Re-engineering: My Disdain, Thoughts, and CALL TO ARMS

Posted by The *Angriest* Pharmacist as APhA, Drive-Thru, Drug Topics, Education, Government, Hospital Pharmacy, Just a question, Management, Me being a dick, Me hating others, Money, PHARMACY SECRETS!, Politics, TPA, True Story, Work Sucks

P.O.W.E.R. — (n. – ENG) Pharmacy Optimization With Enterprise Re-engineering.

It’s okay. It hasn’t hit my area yet, but my fellow citizens aren’t stupid. They are asking what it is, what my thoughts are, and what they should do. [Again, you have my word that I do *NOT* work for Walgreens -- at all...] Anyway, my marquee is exactly as I said it would be (Yes, heart included):

Your Rx Filled RIGHT HERE
by OUR Pharmacist ♥

It’s going over good. Some people know and they like it. Others don’t know and they ask…so I’m starting the word of mouth of all the rumblings and grumblings. All the fodder I need is on the Student-Doctor Network or other various message boards.

Everyone has a problem. No one has stated, supported, backed, and pushed a solution….We all know what it is. We all know what it would take. We all know what it would stand to gain. A TRUE Pharmacist’s Union is necessary, with the focus on us and the preservation of the profession as a primary goal and focus on the patient being synonymous with that — i.e. without a happy pharmacist, you cannot have confidence in the safety/best medical practices for the patient. It would be ridiculous in the power it [Such a union] could hold.

There are close to 60,000 pharmacies in the United States. With a diverse (randomized amongst the chains/businesses/clincal/hospital) group out of the some 220,000 pharmacists working those stores/locals, we could nearly control the flow of pharmaceuticals in this country (bring balance to the force).

Would we ever go on strike and grind the pharmacy business to a screeching halt — less the SCABS? I doubt it, but we have to be willing to do so to foster/compel change. We have taken Oaths to serve the public in positive manner (like the hippocratic oath). But, a collective bargaining agreement, could be much in our favor due to the 100% necessity of our presence at all times in every pharmacy in the country and governed territories. We could also bargain/work to set ‘maximum-allows” and work-flow/safety standards. So, a pharmacist cannot exceed say 300 scripts checked per 10 hour shift (Contradicting MY EXAMPLE, I exceed that on certain occasions, but all I do is check, no count – no type [mostly ALL single RX refills] which bugs the fuck out of me!), let’s say 5 techs working at a time to be monitored per RPH (again, examplenshot out of a cannon), required 30 min lunch taken outside of the pharmacy as well as maybe even a 15 minute break, otherwise your company must pay you $200 to miss lunch and/or $75 to miss a break or something egregious (I may go hungry for a price!). I bet I don’t swallow a sandwich laying on the counter under that deal.

I’ve said this all before….there’s just nothing to protect the pharmacist and his/her interests — only punish them severely after an incident/issue. We’ve given up control of our pharmacies for longer-term financial security and reduction/elimination of short term risk, and in doing so, given away basic job-related / human rights — like going to the bathroom when one must micturate.

Over time we’ve gotten used to not having these simple things that were rights and are now seen as luxuries, and that lackadaisical attitude absolutely sucks…it causes much of us disdain and could be attributed to many errors we may be responsible for….

Now, who’s prepared to lead the charge? Who shares a vision with the majority of people? Who can rally massive support and inspire people to rally to the cause? Who is intelligent enough to see through the bullshit pushed out by the corporations and trustworthy enough to bring the truth to those interested? We need to find that person. Pharmacy needs a ’savior’ — an advocate capable of achieving big things — huge things. It’s gonna be a long, bump-filled, gravel road (which will only lead you to a rowboat with which to sail across the ocean!).

If we don’t find this person(s)…we are going to find ourselves in a position we never planned for. We are going to have our backs against the wall (essentially) begging for another punch to the face.

Pharmacists are currently salaried management making between 50-65 dollars per hour for starting/initial staff jobs right out of school (per my snap judgment/absolute guess on 8/30/09). I’d say store and district management make more / MUCH more (150k/250k respectively on the low side).

Pharmacists — think about the debt you have right now. Let’s really say you’re in deep.
120,000k School Loans (I’d bed the MEDIAN)
7,500k Credit Card Debt (Playstations, Wii, and Drinking)
45,000k You needed a fucking Lexus SUV didn’t you asshole
+/- HOUSE NOTE — Depending on the location and the house this could be a starter at 80-100k or a huge house at 250k if you qualified for the loan (meaning you had less school debt most likely).

If you go from a dollar a minute to a dollar every two minutes due to an artificial decreased demand for your specialty (and you are the unlucky fired)….how fucked are you? Entirely, a lot, a little, not at all (due to mom and dad saving my ass), or this is good for me. Personally, I’d be fucked a lot — even taking into account my wife, and her job, makes more than I do!

It’s cliche as fuck, but UNITED WE STAND, DIVIDED WE FALL. Come together as a single unified profession with a loud voice, or fall apart quietly….as 250 thousand single, quite voices that have been put in their place.

There’s a “Kick-Me” Sign on Pharmacy’s Back

Posted by The *Angriest* Pharmacist as Disgusting, Doctors, Drug Companies, Hospital Pharmacy, Insurance Companies, Laws, Me being a dick, Me hating others, Money, Patient Education, Politics, True Story

I guess we’re the flavor of the month as the douchbags and assholes are coming out of the woodwork to take a cheap shot at our lovely profession. A loyal reader, known only as Bond, sent me the link to an article titled, “The Great Drug Switcheroo.” This piece of shit article published by “Prevention Magazine” (which has been around since the 50’s). The tagline is, “Your pharmacist may be changing your medication without your knowledge–and what you don’t know could hurt you. Here’s how to stay safe.”

Once again, the man behind the counter in the white coat is trying to KILL you — not trying to help you achieve optimal results from your drug therapy. It begins with a story of a lady diagnosed with epilepsy who had troubles finding an effective drug regimen. After she had gotten stabilized, she fell of her bike and broke her leg — all because of an evil conniving pharmacist!

Her pharmacists, she learned, had exchanged her Tegretol for a generic that worked a little differently. “Just imagine what could have happened had I been behind the wheel of a car,” she says.

What’s wrong with this sentence besides everything?

The article then goes into THERAPEUTIC substitution and not GENERIC substitution. The article makes the point with statins as well. The problem with this entire bullshit, whacked-out piece of journalism is that therapeutic substitution does not exist outside of the inpatient setting. I cannot think of a situation where that would be legal, and I seriously doubt it is allowed in any state.

For readers not in the know, here’s an example of THERAPEUTIC substitution: I am working a shift at my local hospital. I receive an order for a patient to receive Crestor 10mg at bedtime. The hospital doesn’t carry Crestor because it’s silly expensive. They do, however, carry Lipitor because they have a contract with Pfizer for a good price for it. The Pharmacy and Therapeutics Committee at my hospital did a review and based on their specific protocol, I can swap in Lipitor 20mg for Crestor 10mg as their lipid lowering effects are very similar (based on the results of the CURVES trial). I don’t need the permission of the MD or anyone else as the P&T committee represents the MDs and they have okayed this sub. There are hundreds of places where this happens — IN HOUSE! It does not happen in a pharmacy as Walgreens does not have a P&T committee…:-)

Here’s an example of GENERIC SUBSTITUTION: Your doctor writes for Vicodin 5/500mg. Name brand Vicodin is really expensive, and I don’t carry it. Luckily, he signed the prescription on the side of the blank that says, “Generic Substitute Allowed.” This means the doctor has given me the authority to dispense a generic drug, Hydrocodone/APAP 5/500mg which has been rated AB by the FDA (meaning it is recognized as equivalent therapy by the United States Government).

I’m pretty fucking sure our seizure chick was getting Tegretol or Tegretol XR for some time and the pharmacists switched her over to an AB-RATED generic equivalent. Can we say that this was the cause of a seizure? Fuck no. This bitch has epilepsy. She can have a seizure after a loud fart — did the fart do it? The time frame fits! I just drank a cherry coke. Can we say that Cherry Coke made me a dickhead? No. I’m a dickhead and it’s expected. Anywho, I SERIOUSLY doubt the pharmacist here said, “Well, she’s been getting Tegretol for quite some time. Let’s give her some Phenytoin. It’s okay…I’m a Pharm.D.!” —- No way….They are sensationalizing this and trying to compare dissimilar things.

The article specifically says, “A generic that worked a little bit differently…” — I know it’s semantics here, but generics are the same drug that work in the same way.

The second page of the article talks of a switch done by a mail order pharmacy. This I don’t doubt happens. They know exactly what drugs their plans will cover,  but by the letter of the law, they shouldn’t be making changes. I’d bet they call the MDs and say, “You wrote for Prevacid. We’ll pay for Nexium. Is it okay if we fill the latter?” — Of course the doctor doesn’t care and the patient gets the new drug in the mail without ever being told of the switch. Is that okay? It’s bad customer service as the patient is likely going to be scared and ultimately pissed, but they most likely meet the legal requirements of the law.

Ask your pharmacist to put a blanket statement in your records that you don’t want any medications switched unless you and your doctor approve. “It’s a way of getting your pharmacist’s attention,” says Catizone. “When pharmacists know more, they can do a better job of advocating for patients.”

We’ve all got a few of these assholes in our system. “I want brand name everything! Generics don’t work for me.” It’s these type of assholes that make me lose money on a bottle of name brand Vicodin when 70 tablets expire in a 100 count bottle. But, if they wanna pay for it, that’s fine by me. I’m not gonna lie and put DAW1 — I’m putting DAW2 and you can pay the difference.

Each section in this pissass article says, “If your pharmacist makes an unapproved switch….”  — What’s the need in this statement? Is there really this much distrust in pharmacy and pharmacists? I’m blown away by this. The final section has a quote from Robert Reneker, MD, urgent care physician at Spectrum Health, a hospital system in Grand Rapids, MI. He correctly says that pharmacies are reimbursed better on generics and switches are profitable. He incorrectly states that we are motivated to make these switches by profit.

I, personally, could give a shit less about what prescription a person gets. I’m happy to get the person in the store and make the sale. Volume is volume and it all averages out. If you get name brand something, you do. I’m not going to go out of my way on each of the 800 scripts I fill a day to ensure it is generic and maximize my profit margin. That’s just silly…to think that one would do that. To change you from Nexium to generic Protonix (pantoprazole) requires a call to the MD, the wait, the recount, and the dice roll that your insurance covers it. I may make more money on it, but it’s it worth the 5-10 extra minutes of work? Never…So his claim here is valid, but off base. He also says that pharmacies have told him drugs aren’t on formulary when they are — he’s checked. This is funny to me because I have no idea what’s on anyone’s formulary, and again, I don’t give a damn. If it’s covered it’s covered. If it’s not, I try something else. I have the broad ideas of what’s covered: generics are, Phentermine isn’t, BZDs aren’t on Part D, etc. For fuck’s sake, I could process a prescription and get a rejection that says drug not covered. Then Dr. Reneker calls the insurance company, and they say, “Prevacid? Why sure it’s covered, Dr. Anything you want. Let me send you this form to fill out.”

Dr. Reneker understands that to mean that: The drug is covered. I just got the prescription for my patient. The pharmacist lied to my face. The pharmacist  sees this as: I tried to process it and it was rejected as NDC not covered. The MD called and got a Prior Authorization. Now I can fill it and the patient can pay $75 while Prilosec is 20 bucks for 42 tablets. Way to go, Doc! You think you won, caught a pharmacist in a lie, and got the patient the medicine. The fact of the matter is the insurance company won (twice), you now distrust me and don’t know the whole story, and the patient can’t afford the food anymore that causes her heartburn.

Above is an example of what happens when a journalist talks out of their ass.

I’m not sure who makes the above switches. They are insinuating that you bring in a prescription for Lipitor, your pharmacist is going to send you home with Simvastatin and there’s not a damn thing you can do about it. Well, that’s fucking bullshit. While these substitutions are all fine and dandy, I certainly wouldn’t do them on my own accord. However, Prevention magazine thinks I can and do.

Read REMOVING THE WOOL to see what changes could be made where the new isomer-removed-new-drug/patent-game-type name brands exist and the generic would be cheap to use and work just as well.

TAestP is a HERO!

Posted by The *Angriest* Pharmacist as Doctors, Hospital Pharmacy, Stupid Nurses, True Story, Work Sucks

That’s right. Today, I lept from the world of pharmacy into the area of HERO.

I was at the hospital — doing a little bit of ‘consulting.’ I decided to have a little bit of lunch. Of course, TAestP is a loser (and rejected by physicians) so he eats lunch alone.

As I was sitting in the quaint, 80-bed hospital lunch room, I saw the man sitting adjacent to me clutch his chest. He let out a resounding, “HRRRPMPHH!” I assumed he was having a heart attack as he was around 1-ton, eating a cheeseburger, and “HRMPH” is the requisite M.I. sound.

He fell to the ground like a rotten bag of potatoes. It was much to sudden to be an MI. It appeared more like he was having a seizure to me. A heart attack this was not…

I considered laughing (on the inside, I did). Instead, I lept into action. I went to his side, and I did the only thing I could think of. I mean, I’m not an emergency medicine physician. I pointed at some random nurse and instructed him to go and get me the AED.

I pounded my fist onto his chest as hard as I was able. That’s right. I performed a precordial thump. He may not have been in cardiac arrest. He could have really been having a seizure.

I contend that he would have been happy with my efforts — if it would have cost him a few broken ribs. Well, it turns out I did the right thing. He was going into ventricular tachycardia, and my little “5-10 joule” thump knocked him right out of it without the assistance of an AED — but I did break a rib. He was 60+ years old. That fucking guy is lucky that I didn’t crush him like a bag of Doritos as I was much larger than him…

Nonetheless, I am a hero. The hospital is going to give me a plaque. The newspaper is planning a story. I’m a big deal…

Lots to address

Posted by The *Angriest* Pharmacist as Education, Hospital Pharmacy, Patient Education, True Story

Hello world! Buckle up, we’ve got a bunch of issues we’re going to cover today. The first relates back to a recent post about how to bust a fraudulent prescription. Watch this video about the prescription drug problem in Michigan. Turns out, they have an awesome system tracking prescriptions. They can view in real time all the patients that are doctor shopping, track the number of pills they’ve received, and even access all of their information. This is, of course, not a public database. Yet, the agency charged with tracking this data and generating the reports has no ground to stand on — as it’s not illegal in Michigan to “doctor shop,” and the state prosecutor doesn’t want to waste his time on these cases — he just wants the big dogs…for the glory of the big bust and getting his face on the evening news…What a crock of shit.

The funniest thing about the video is the very last sentence the reporter speaks. The lady they had all but busted doctor shopping refused an interview and said she was merely seeing all those doctors because she was going out of town and she needed to make sure she had enough Vicodin to last her. I just fucking wonder who paid for those prescriptions — it sure as shit wasn’t her, and I’d bet anything she made a good amount of money selling them on the skreeet. It’s a dollar a milligram in my area for hydrocodone and oxycodone (yes, they are considered the same per street rules). Xanax usually runs 10 bucks for 2 milligrams. Anyway…

If one breaks the law, regardless of how big of an issue it may be, it is the job of the prosecutors to see the case to fruition whether it be court, plea, or otherwise. Hopefully, you guys can get this changed! I’d really like to hear from some of our Michigan pharmacists — you guys have access to this program, Michigan Automated Prescription Service (MAPS), do you use it? Is it accurate and trustworthy? Do you use it to check sketchy patients and subsequently use it to deny them service?

-=+=-

I’m sure most of you have noticed that my number of posts has recently gone from 5/wk to 0/wk. I’ve gotten about 20 emails asking me where I’ve been! Have I gone on vacation? Did my dog die? Did my dox get dropped? Make no mistake – if I go on vacation or something happens to me, it’ll get on the website somehow. My last will and testament has direction for how to notify readers of my untimely, but all to expected, death…:-)

I feel awkward announcing this to the world. I’ve gained all my steam on this website because of my job. I am a community/retail pharmacist in Anytown, USA! Well, starting last Wednesday I’ve been working in a highly clinical role.

The clinical pharmacist at my local area hospital decided he wanted to get drunk in Hawaii for two weeks. Last year, they paid tons of cash to bring in a replacement for the two weeks. This year, the approached me about a month ago to see if I could do it. I’ve known the clinical guy there for quite some time. I spent the weekend prior to his vacation with him getting trained on my duties, their computer system (which is sweet), and pretty much everything a new employee would need. And yes, I had to watch that stupid fucking HIPAA video with the red headed lady that eavesdrops all over the hospital.

So, I arrive there at about 6am. There are three teams right now, and I am on two of them (the third team has a Pharm.D., MD on it…showoff!). Rounds for Team 1 start at 7:00am, and rounds for team 2 start at 8:30am. I do Vanc/Gent for the entire hospital. I also modify TPNs. Physicians set the initial TPN, and I modify them based on patient needs and expenditures (This was the HARDEST thing to remember for me because of the chemistry/equations I hadn’t touched in 5 years – at least Vanc/Gent is plug and chug)  I also narrow therapies based on C&S and patient needs. I’m also seeing that everyone gets normal health maintenance stuff while in house (stress ulcer prophylaxis, DVT prophylaxis, vitamins, vaccinations) – this was an initiative initiated by the normal clinical guy. I also do all discharge education (obviously).

I’m not a BCPS (Board Certified Pharmacotherapy Specialist) like he is, but I think I’m getting along just fine. Apparently, I’m eligible to take the exam — it’s 3 years after you graduate or immediately after you complete a residency…I’m not sure if that’s true or not. Anywho, the physicians all respected him immensely — and rightfully so. He is the smartest fucker I’ve ever met. I shit you not, I never asked him a question he didn’t know. He’s like a walking Koda-Kimble-Dipiro Database. That has been good and bad for me. Good in the sense that the physicians all believe in the importance of me being on the team because of the asset he is but bad because I don’t know everything he does, and I have to use the ole idiot-student-reply, “I’m not quite sure. I’ll research that and get back to you as soon as possible.” Needless to say, I look up quite a few things.

I’ve answered a lot of questions on rounds. I feel like I’m really an asset. They all appreciate and respect me, and it makes me feel all tingly inside. I was even asked to be the ‘leader’ of Grand Rounds this week. Essentially, I presented a current patient case then educated on a disease state. I chose my favorite because I already know a lot about it — Cirrhosis and associate complications. I talked about it all: portal hypertension, varices, acute management of variceal bleeds (including some preparation guidelines that I created for the hospital so that they had shit ready to go in case a cirrhosis patient pops a bleed – somatostatin, rapid infuser, plasma, platelets, blood typing/Rh factor early and blood stocked closely), hepatic encephalopathy, Child-Pugh classification….everything.

I got a good reception. I think it went very well, and I didn’t sound retarded.

And, of course, some dickhead doctor asked me a trick question — trying to throw me in front of the train, and I caught it and fired back.

“What are normal ammonia levels?”
“This institution considers 10-75 micrograms per deciliter within normal limits.”
“And, based on your clinical experience, at what level of hyperammonemia do you initiate treatment?” [Yeah...he was being a dick here. This was only like my 7th day there...ever...I have no clinical experience, but I knew the answer.]
“Actually, that’s a common misconception. You do not initiate treatment in cirrhosis based on ammonia levels. Ammonia levels alone do not dictate the presence of hepatic encephalopathy. Some patients could have a level of 80 and have severe symptoms, and another could have a level of 100 and be asymptomatic. Ideally, we would treat as symptoms emerge such as asterixis primarily, impaired cognition, confusion, agitation, euphoria, insomnia, and reversal of day-night sleeping pattern.” [I had them written down.]
“Oh. I see…” [He knew it. He just wanted me to fail.]

A few minutes later, he asked me about hepatorenal syndrome. I omitted it from my presentation because there really isn’t much to say, and we don’t have a hepatologist or a transplant team. I mean, there’s two types. In type one, you die within a month. In type two, you die within 6 months. He asked me what the cure was…

“The cure? Well, you can try an extensive fluid challenge to unlock the renal vasoconstriction — something like 2 liters with a rapid infuser. It won’t work, but you should try it. Most likely, your patients with this have advanced cirrhosis and will be on the liver transplant list if eligible. If they develop hepatorenal, you’d need to move their name up on the list quite a bit…”

Well, that’s about it.

I don’t really like the sound of, The Angriest Clinical Pharmacist. They’ve offered me the position on a semi permanent basis. Just a few days a week. Since winter is approaching they are going to expand to 4 teams. However, if I took it, I could no longer be the PIC at my pharmacy…so no deal…

Retail is what I am…I haven’t had my fill yet…:-)