Scaring a doctor shopper straight before it’s too late
Young lady brought in a prescription today for #14 Vicodin. I'm not sure why doctor shoppers haven't figured this out yet, but one of those ignorant comments you make is, "I DON'T WANT THIS RUN ON MY INSURANCE!" That comment immediately raises my suspicion level.
Now, this young lady didn't say that -- it was a variant that can be equally suspicious, "How much does this cost? Cash Price. I no longer have insurance." The fact someone says this isn't always suspicious, but the fact she said it twice (and awkwardly at that) did set off my bullshit detector. She told me that she wasn't on file -- luckily she was -- and lookie there....A MEDICAID CARD! I, of course, didn't tell her that I had this information.
I ran it, and low and behold, it rejects. I call up Medicaid to inquire about doses, quantities and where. They tell me a Norco 7.5/325 #90 (30 day supply) filled at a nearby CVS about 14 days ago. [The Medicaid agent gave me the Fraud Line and urged me to call. She also said that the new Rx could be filled in NINE DAYS based on carryover days, etc.] The Vicodin prescription was written 4 days ago. I called CVS, verified Name, birthday, medicaid ID number, and made sure it was picked up. Now, we have a problem.
I wrote her Medicaid ID number right next to her name (very big). I also wrote a note explaining the entire situation on the face of the full page prescription. When she came back to pick up the prescription, we had the following exchange:
[The most unfortunate thing here is that while the following is occurring, there is a 4 or 5 year old little girl stumbling around in front of the pharmacy munching on a cherry Dum-Dum I had given her...unable to comprehend the gravity of what was going on in front of her...the mistakes her mother was making before her eyes.]
"We have a bit of a problem here. We had you on file, and we happen to have your Medicaid Card and ID number on file. As we ran this it came back that it was a refill too soon and duplicate therapy."
"I don't have any insurance or medicaid. I didn't fill anything at CVS..."
"Stop lying to me. I called Medicaid and they told me that #90 Norco 7.5/325 tablets were filled at CVS 14 days ago. I called CVS and verified this information. They also checked the signature logs and found your name signed to the electronic pad. Now, if you genuinely have no idea how this prescription got filled or what is going on here, I can pursue this matter further. However, if you are lying to me, of which I have ZERO reason to believe you are telling the truth, this will end very badly for you."
"No Sir. That won't be necessary."
"I was told by Medicaid that you can fill that in 9 days. I wrote that date on the prescription along with a little note in case you decided to try and take it anywhere else. I've also notified the area hospitals, clinics, and pharmacies through our area 'doctor shopping fax tree.' I also have no choice but to call the Medicaid Fraud Line and notify them of this. I hope these measures prevent you from making any more attempts to acquire controlled medications. Up to this point, you haven't been caught. In the future, you will get caught, and what you are doing is a felony, and it's fraud. Now, for your young daughter's sake, I would hope you turn over a new leaf."
"I will. I promise. You don't have to worry about me ever again. You don't have to call anyone about me. I'm sorry. Thank you. Have a nice day...." [And she scampered off as quickly as possible with her daughter in tow.]
For what it's worth, I did not call any hospitals, doctors, or clinics, and we don't have a "doctor shopping fax tree" (but now that I invented the idea of it, it sounds like a great idea!). I also have no yet called the Medicaid Fraud Line because I was on hold for more than an hour (I left it on speaker), so I gave up and hung up. I said all that stuff in an attempt to scare a 23 year old girl back onto the straight and narrow path. Maybe it was too harsh. Maybe I was wrong in doing all of that. What do YOU think?
Does ANYone fix inhalers?
I had a guy come in today with a broken Ventolin HFA. He had OBVIOUSLY broken it. As you know, you can remove the cannister from the plastic delivery device. At the bottom of this cannister is a little white piece of plastic. When this piece is pressed, the aerosol is given an exit from the cannister. Usually, this is directed out of the plasic device. Well, this old man had broken the white piece off, somehow, to where it cannot be pressed in at all. Obviously, this is my fault.
Additionally, he had the plastic device jammed into a Aerochamber in reverse -- so if you somehow were able to dispense a dose, it would spray upwards rather than into the chamber.
Now, I can see how one could say that this is merely a failure on the part of the pharmacist to effectively counsel on proper use of the inhaler...and you're probably partially right. In all likelihood, when he picked this up for his child, we BOTH assumed that a grown man would have sense enough to either use an inhaler with aerochamber or read one of the three separate inserts / literature that were purposefully put into the patient's bag. The assumption was proven incorrect. This patient was obviously too intelligent to be bothered with reading those stupid papers that patient's so often vehemently deny and exclaim, "throw all that crap away I've got tons of it at home," only to attempt to jam a square peg in a round hole and break the entire contraption. Wow...just wow...
Finally, this gentleman was mad at ME for not repairing the inhaler OR replacing the inhaler at my cost. I got him an override for an early refill (the TIME spent was my cost...right?). As he left he asked "when the boss was gonna be back." I, of course, don't do well with this comment because it's a slap in the face and passive aggressive. Just tell me what your fucking problem is and assume I have sense enough to come to a reasonable end-game.
Prior to this I took the time to look up the number to GSK for him to call and see a coupon or refund for the product he obviously broke. He was mad about it still, and his only concern was "What if I pay for this one, get it home, and it don't work neither?" -- Well, considering you broke the first one, I'd say the likelihood of you breaking another is rather high considering you still haven't opened up to me trying to show you how to effectively use it...Alas, you have more copies of the literature (illustrated ones this time -- for the kids!). If you don't break this one and it "still don't work" -- it's STILL NOT MY FAULT.
I'm sorry, I don't service inhalers. No pharmacy does. If it doesn't work, it's the manufacturer's fault. If you don't know how to use it -- that's my fault. I've done what I can to help on that front. You're gonna have to be a big boy and make a phone call for the rest -- rather than "gimme gimme gimme gimme..." like usual...
Pharmacy Class of Trade
I got the following message from Steve Moore, an independent Pharmacy owner. I wasn't sure what to do with it or how to share it with the world. Therefore, I'm just going to post it here for all to see. I'm not going to post his contact info, but he's welcome to post that in the comments section (as well as links and references).
---------------
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.
Requirements versus Services
The smart alecks that post wise guy comments on my, and other pharmacist websites, usually only have one or two things they say regarding the worth of pharmacists. The root of their hatred for the profession that does so much for the common citizen is seeded in their jealousy of the wages paid to such highly trained professionals. Along the same lines, they only see pieces of paper (money and prescriptions) coming in and bottles filled with 30 pills each going out. Haters see it as overly simplified. Exoterically, from the outside looking in, it is, but for those of us that spent 6 to 8 years getting a doctorate, we don't agree. Compared to backbreaking labor outside in the hot sun, I can at least understand.
I've also had a recent brash of problems with patients being rude/uncaring about the difference between requirements of a pharmacist versus services provided by a pharmacy. Some things we do are required by laws, federal or state, while some things are done to ensure patients have a good pharmacy experience and return with more pieces of paper.
Requirements:
1. I take the prescription from you. I ensure it meets all legal requirements (Name, Date, Drug name, directions, quantity, refills, doctor signature, and in my state, the Rx symbol on the face of the prescription).
2. I input in the computer (the computer system is not required. I could use a typewriter or even hand write the labels).
3. A prospective DUR (Drug Utilization Review) is performed by either the pharmacist manually and/or the computer system automatically ensuring that there are no drug-drug, drug-disease, or drug-patient interactions requiring concern. If there is, the physician in contacted. The patient is educated or the drug is changed to an alternative at this point. If there is no problems, we move on:
4. A label is generated and placed on an amber bottle.
5. The appropriate drug is counted and placed into the bottle.
6. Final check is performed by pharmacist and all aspects of the process is verified again. Finalized product is bagged and put into the pharmacy's WCB (Will Call Bin).
7. Patient picks up medicine. Patient is provided the opportunity to ask a pharmacist any questions concerning the medicine with the magic question, "Do you have any questions for the pharmacist?" -- this requirement not being added until 1990.
Services:
1. Billing your prescription insurance (or Medicaid) for the cost of your medicine (I don't have to take any insurance - let alone YOUR insurance). Some compounding pharmacies refuse to accept insurance and are cash-only.
2. Calling your insurance if their is a problem such as them not wanting to pay for the expensive name-brand drug your doctor wrote for, the quantity he wrote for, or for any of millions of other reasons they could dream up. Perhaps you remember when CVS made the decision to not call your insurance for problems any more. They accomplished this by placing a phone in the waiting room. It didn't go over well, but it proves my point.
3. Calling your doctor for refills when your prescription runs out. This is the job of the PATIENT that has been performed by pharmacy's striving to merely keep patients from having the opportunity to take their pieces of paper elsewhere if they are forced to visit the doctor for refills.
4. An easy open lid is placed on your bottle instead of the safety lid which is the legal requirement. (Screw your arthritis - I don't have to cater to you!)
5. Paging your name overhead when your prescription is ready -- that's all southern hospitality, buddy!
6. Taking checks or credit cards is also optional. Cash is the only requirement -- read the dollar bill. Does your credit card or check say that I *have* to take it? Nope.
7. Flavoring your child's antibiotic with out FlavorRx system.
8. Anything or everything related to having a drive-thru or providing services through it.
9. Being nice to you in any way, shape, or form. I just have to be there and be sober...I don't have to be my normally delightful self...
I'm sure this second list has a BUNCH more items on it. Fill in the holes for me...I'll add them to the list.
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