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My name is Steve Moore and I am an independent pharmacy owner from New York.  I am wondering if you would consider sharing your thoughts on the following topic, one I think that most pharmacists would be interested in.

When it comes to business side of our profession, most pharmacists don't have a clue as to what is going on.  As an owner, it affects me more than most, and I don't comprehend all of the complexities.  After speaking to some other pharmacists in my area, I came to realize that they are under the impression that mail order pharmacies were simply discount pharmacies, that mail order just filled prescriptions at a lower price than retail pharmacies.  That may or not be true, the larger issue is that mail order pharmacies are able to offer deeply discounted medications because they are purchasing medication a better price than retail pharmacies.  PHARMA grants them a special class of trade (COT).  I attempted to find a law/rule/etc that grants mail order pharmacies these special buying privileges as a different COT and was unable to do so.  I wrote to consulting companies and wholesalers and I was told that there is no such list.  If there is no government approved or provided COT list, what makes mail order special other than the fact that PHARMA says so?

My question is, if mail order can do it, why can't community pharmacy designate itself as a special COT?  Mail order promotes safety and accuracy, we have a robots and workflow too.  We can fill antibiotics and pain meds, mail order cannot.  We can deliver meds the same day, mail order cannot.  Mail order simply cannot meet 100% of our pharmaceutical needs.  If any group deserves a price break from PHARMA, shouldn't it be the group that can meet more needs?

There is a federal law known as the Robinson-Patman Act which specifically prohibits companies from selling the same products to competitors at different prices (order of magnitude wise).  Exemptions to this act exist to allow nonprofits (such as hospitals) to purchase medication for their own use at a discounted price.  In addition to the hospital COT, there is a 340b class (for now), a long term care class, and depending upon who you ask, anywhere from 7 - 23 classes.  The one constant is that the retail pharmacy COT pays the most for medications.  COT designations have been challenged in the past but were usually lost on the basis of own use.  That meaning, the nonprofit was purchasing medications to use for its patients/employees/etc and was not in competition with retail pharmacies.  Mail order pharmacies are for profit and are clearly competing with retail pharmacies, so in my mind a Robinson-Patman exemption should not apply.  I understand supply and demand and that some people can pay more than others for the same product, but we are not talking about a few bucks here and there, rather exponential differences.  The local hospital pays about $9 for 100 tablets of brand name Coumadin, what does the price sticker on the bottle in your store read?

The fact that mail order pharmacies are buying  medications at a lower price than retail pharmacies has an impact on every pharmacist filling 90 day prescriptions at retail for mail order rates.  I am not saying that if reimbursement improves, working conditions will improve, but it can't hurt to make pharmacists aware of what is going on.  I have contacted our trade associations and industry publications but am also reaching out to bloggers such as yourself.  If you feel that this may be something you would like to blog or post about, I can provide some links and references.

Thanks for your time.

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...:-)