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).
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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.
Removing the wool
Many people in this world have wool drawn over their eyes. In some instances, this wool only causes their opinion to be skewed because they cannot see the big picture. When it comes to the field of medicine, this lack of vision causes the patient to get screwed over. I've hit on this before, but I'm going to discuss it again...because it really pisses me off.
In chemistry, many compounds are composed of isomers. Isomers have the same molecular formula but are structurally different. Basically, they are shaped a little different. Sometimes, the isomers have the same results in the body. Other times, the isomers of a compound have different effects altogether. Still yet, some isomers cause side effects and the other isomer gives us the intended result (or one isomer is active and the other is completely inert). All compounds are either levorotatory or dextrorotatory (Called l-DRUG or d-DRUG *or*Â (-)-DRUG and (+)-DRUG, respectively). Levo compounds rotate polarized light (in a polarimeter) counterclockwise and dextro compounds rotate the same light clockwise.
I'm not going to get into the difference between constitutional and spatial isomers, cis/trans isomers, or R and S notation. Mostly because I will get out of my realm of knowledge quite quickly.
Most drugs out on the market are racemic mixtures. This means that they are combinations of d- and l- isomer. Most drug companies have fucked the common man by doing some shady shit (thereby pulling the wool over everyone's eyes).
Citalopram (Celexa) is a racemic mixture. Only the Dextro isomer is active. It was a heavily used drug indicated for major depression, social anxiety disorder, and panic disorder. Forest spent millions ensuring that every doctor had a big breasted woman peddling the drug to them praising it. It *was* the best available. Until the patent ran out. Then, it was no longer good enough. Now, the inactive isomer has been removed. Escitalopram (Lexapro) is now the best drug available if you ask the crooks at Forest. It is also indicated for depression, social anxiety disorder, and panic disorder.
Here's some more (all with the exact same story -- new drug is "better"):
Venlafaxine (Effexor)Â ====>Â Desvenlafaxine (Pristiq) -- Wyeth
Loratadine (Claritin) ====> Desloratadine (Clarinex) -- Schering
Cetirizine (Zyrtec) ====> Levocetirizine (Xyzal) -- Pfizer for Zyrtec/Sanofi for Xyzal
Omeprazole (Prilosec) ====> Esomeprazole (Nexium) -- Astrazeneca
Methylphenidate (Ritalin, et al) ====> Dexmethylphenidate (Focalin) -- Novartis
Dexchlorpheniramine, Dexbrompheniramine =
Chlorpheniramine, Brompheniramine -- Various Manufacturers
Albuterol (Proair, Ventolin, Proventil) = Levalbuterol (Xopenex) -- Various/Sepracor
Imipramine (Tofranil) = Desipramine (Norpramin) -- Different Manufacturers
Nortriptyline (Pamelor) = Protriptyline (Vivactil) -- Different Manufacturers
In every case where the same company is involved in the new drug, no improvements were made. Of course, the manufacturers would lead the unwitting MDs to believe that side effects were cut down, efficacy was increased, and the old drug causes users to grow an extra appendage on their neck. So, "everyone needs to be switch NOW! In fact, here's a stack of preprinted prescriptions for you to sign and hand out to your patients."
I say fuck that. No one ever asks me about these new drugs, well, now I'm saying it. All this shit does is cause more work for me. How, you ask? Has anyone out there ever gotten a Xyzal to go through? Hell no you haven't. Why not? It's too fucking expensive because the same drug is now available OVER THE COUNTER. So, I have to call the MD and have them get a PA. Then, some nurse wastes time calling the insurance company. Then, the patient has to pay a $45 copayment for a drug available on aisle 9 for $5.99/15 tablets. These drug companies are out of control -- as profit margin continues to shrink and edge closer and closer to 2%, these fucking guys are finding new ways to nickle and dime us indirectly. The time wasted, along with the crap repayment from this drug of equal efficacy, is merely another way to bone us.
Make a stand with me. You get a script called in or brought in for these damn drugs, call the doctor. Get it changed. They don't answer or you leave a message, change it anyway. Make it a "fill--call." If they say no, call the doctor a stupid motherfucker then overlook it. He'll never notice or know.
He's too busy with his head buried in some drug rep's tits pushing the new DRUG OF CHOICE FOR GENERALIZED ANXIETY DISORDER -- levoparoxetine or desmethylfluoxetine or some other bullshit.
Mind Your Own Business
The Angriest Fiance and I visited a local eatery tonight. Not a high priced place like PF Chang's, but we certainly weren't at McDonald's. Quite frankly, I think the place is into witchcraft. I saw their delicacy of choice in a large tank of dihydrogen monoxide when I entered, and they were brownish black. Yet, when they served me a dead one to eat, it was obviously bright red. Either they are wikken-kind or someone has some talent with the paint brush in the kitchen.
All kidding aside, it was 9pm. It was an odd assortment of customers. We sat across from a black man and woman. It was her birthday. Our waiter was amazing. He was polite, quick, and always around when he needed to be. Anyway, it was the lady's birthday - she was rewarded with a free daiquiri for her achievements.
As our wonderful waiter was serving us our salads and asking us if we needed anything else, our neighbor across the aisle decided that he needed my waiter's attention more than I did. I guess he didn't notice the fact that I had a male waiter, while his server was most definitely a female. Nonetheless, he let out a resounding, "Excuse me!" while a salad was being placed before me. In pure Angriest-Pharmacist fashion, the waiter ignored the man like he was a fart in the wind. After we were tended to, the waiter's response was perfect. He acknowledged the man (barely), told him to wait just a second as he returned the "serving table" to the back, and walked away. He never returned -- however their waitress came by a few moments later. I found this absolutely hilarious.
Finally, they brought out our main course. I proceeded to chow down on my feast before me. As most may know, there is some splatter involved with food that lives in water. You break a hard shell to get to the sweet, succulent, heroin-like substance within. I'm also a very, very, very messy eater. I got a little on me...and my date. She was not as amused as I was.
Our neighbors thought my entire meal was quite funny. They giggled and laughed. Hell, I think they pointed. It was pretty fucking irritating. I'm not sure why someone would spend more time watching someone else eat than staring at their own food and their own wife's tits. I hope they enjoyed my dinner - I did.
Moral: Keep your eyes on your own fucking plate.
Tip on $50 check? $15 for service. $5 for ignoring rude ass people.
More sins? What's next – cheap prescriptions?
In case you were unsure beforehand, you *are* going to hell. The Vatican just solidified that in stone by adding a few new sins.
• Environmental pollution
• Genetic manipulation
• Accumulating excessive wealth
• Inflicting poverty
• Drug trafficking and consumption
• Morally debatable experiments
Let's talk about them for a second. Environmental pollution -- new age sinning created just for those of us in the 21st century. Gideon's Bibles anyone? What about making birth control "wrong" as the church has done? Doesn't that contribute to overcrowding and pollution? Sure it does. I wonder if burning witches contributed any to the greenhouse effect? Heck, it could be the cause! Witches in the atmosphere could be what Al Gore is trying to expose here...
Genetic manipulation -- this is a load of bullshit. I wonder if monoclonal antibodies fit in here? What about the cancer that God allowed someone to get? It's a manipulation of a gene. Is someone that gets cancer a sinner - or is just the cancer going to hell? What about the delicious corn I had for dinner last night? It was manipulated to grow bigger, faster, and more delicious. Is the corn a sinner, or am I a sinner for eating it?
Accumulating excessive wealth -- wow. "Don't get money, but if you have it, go ahead and give 10% to the church and we'll absolve you." Holy shit - what if someone wins a lottery? What about a high stakes bingo game? -- that the church held? Michael Jordan is a sinner for being loaded - just because we paid him to put a ball through a hoop...What about Bill and Melinda Gates -- arguably the most generous donators of all time (Microsoft stuff withstanding). What about me? I make a healthy wage - some would call it excessive. It's obviously more than I need because others have less and do fine. Of course, we knew I was going to hell. I wonder what the GDP of Vatican City is...
Inflicting poverty -- I'm not even going to list the number of people this makes a sinner...including the church. Of course, they've helped billions...but how many fathers died in the Crusades (any of them) leaving wife and son in poverty and/or servitude? What about me - having to charge hundreds of dollars to a patient for lifesaving therapy? Or the drug company charging my wholesaler an arm an a leg for that drug? Or even the PBMs gobbling up all the profits from every direction and, in a way, making us all just a little bit poorer?
Drug trafficking and consumption -- I looked this one up for clarification. It includes consuming any drug that has a mind altering affect. You've got to be fucking kidding me? Not only is every person in America a sinner, I am the Harbringer of Death. Alcohol, caffeine, Xanax, opiates, Barbiturates -- if it breaks the blood-brain-barriers, the Vatican says, "NO!" And trafficking? Again - talk about pointing a finger directly at me...SHIT! Next point - let's make alcohol a sin, but continue to gobble it up during service, at the beer wagon during the school carnival, and any other time we see fit. It's only a sin if you drink more than the Catholics do...if you drink less than they do, you are a pussy.
Morally debatable experiments -- Whoa. Think about all the pertinent medical research that won't get done now because some zealot sitting on an IRB will read too much into this, consider risks more than benefits, or just not even listen at all (as Christians are so good at doing). Now, I'm not defending research that consists of "let's stop this heparin drip and see how long it takes a clot to develop in various patients" -- I'm defending research that I don't understand, know that's going on, or may/may not involve some part of a zygote (don't even type the fucking word fetus on my website - I'll snap. Fetus = 8 weeks+ Which is why I could care less about dispensing Plan B...) Regardless -- this is going harm medical advancement for the years to come. I wonder if this refers to private bedroom experimentation between the sexes? I mean, come on...we've all *ahem* Nevermind. Let's just say that this may be targeting certain sexual preferences...not like the church would ever do that....would they?
Overall, I feel cheated that I have more ways to sin and find my way into Hell than those born in the 19th century. Why do those horse riding fools have a better chance than me of getting into heaven? Bogus. More importantly, can I get any ex post facto leniency here? Doubtful. I've got all kinds of purgatory headed my way -- don't I?
NOTE: Before commenting, read the URL of this website.
NOTE 2: If you post one fucking word about the prescence or absence of an almighty, I will be the one doing the smiting. I'm not looking for theological discussion on this site. I just merely wanted to bitch a little about these new rules some people have to play by that don't make and damn sense, are somewhat hypocritical, and don't apply to me cause I don't give a rat's ass.
Thundercats are go...
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