Quotes of the Day: August 2010

This is a new section I decided to add since we all know that sometimes the best one liners come in retail pharmacy!

Patient: What's that do? (pointing to image below)

Patient: I didn't have this transferred I had it filled at another pharmacy!

Patient: What does script 2 of 2 mean?

Me: It means the ER gave you two prescriptions. Do you have the other?

Patient: No I just want the tramadol not the antibiotic.

Me: I never said you had an antiobiotic, ma'am.

Patient: Well they only gave me one prescription!

Patient: Where do you find bed bugs? In bed?

Patient: You have a drive thru? That's just like McDonalds!

Me: Ya, except we don't spill your pills all over your bag.

Patient: Do you have Plan B?

Me: Yes we do and it's around $55.

Patient: Thank God, my mom got me this gift card!

Me: Ma'am, we need to call your physician to clarify your prescription.

Patient: Which doctor are you calling over there?

Me: Dr. Phuc Nguyen (last name said Win, no joke this is a REAL name!)

Patient: What did you say to me?

Patient: Which of these makes it, uh, smoother? (spoken in broken English, and simulating a penis and vagina with his hands)

Me: Well I think the medicine for your wife's yeast infection will help and so will the rash cream for you.

Patient: Really?

Me: Sir, may I have your date of birth?

Patient (who's in the clergy): Hell no! I don't want one of these cougars knowing my age! (while staring at the woman behind him)

Me: Well can I check your address?

Patient gives address

Me: Well, now they know where you live.

Patient: Aw damn! Now I gotta go stock up on my cougar killing ammo! Where's your condoms?

Lastly...

Patient: Thanks for your time/help!

Despite all the funny things that happen in retail, its all the people its the people who appreciate what I do that make me glad I worked my butt off to be come a pharmacist!

Medcaid Fraud May Be Legal, As Long As You Get Their Permission

Medicaid fraud totaled around 12.9 million dollars in 2007 according to the U.S. Office of Department and Management. Medicare fraud was slightly less at $10.8 billion. Though this number may sounds shocking a fair amount of this may actually be due to the Medicaid and Medicare itself.

Near the close of business today I had a phone call come in from a patient's parent asking us to refill her son's necessary medication. I obliged and went about my regular duties while my technician filled prescriptions and did other small tasks. Withing 30 minutes of calling a woman showed up to pick up the prescription that was phoned in for a refill. I looked up the desired prescription and saw it was in troubleshoot due to an insurance problem. This is where it the government based programs ALWAYS get something wrong.

I opened the prescription on and saw that the problem was that Medicaid claimed the prescription was not properly billed to the child's correct primary insurance. To clarify his parent were divorced and his mother had custody BUT his father had insurance that still covered him and therefore must, by law, be billed previously before billing Medicaid. I double check with the patient and I had all of the correct information in the system. I fiddled with some rejection issues for billing 2 different insurances that I have picked up along the way. Still to no avail.

This means I have to face every pharmacists nightmare. The dreaded insurance call...

I got through amazingly quick (probably because who the hell is filling prescriptions on a Friday nigtht that isn't a pain med or possibly birth control). When I get through I am connected with Gino who was surprisingly pleasant throughout the call, unlike most people who I reach when calling Medicaid. I explain to him the problem, that the insurance is being billed correctly yet I can not get Medicaid to cover the rest. Gino gives me several more options that I did not previously try but all are futile.

Then it dawns on me.

I can go back and see how the prescription was billed previously. As I pull up how this prescription was previously billed I mention it aloud to Gino. Gino says, "Well that makes sense since that was the billing number that kept coming up on my screen." There is one major problem though. With the way I am billing this rather expensive prescription I am telling medicaid that I am actually billing a different insurance company than I am and I am also saying that I did not collect payment from the primary insurance. Basically I am telling Medicaid that I am not getting paid for this and they need to pay it in full.

This is Medicaid fraud by the book!

"Wow, you're right! My system is saying that's the only way we can cover this prescription but they are literally telling me to falsely file this claim!" I ask Gino to leave a detailed message for his supervisor and he gladly obliges. I can actually he him scuttering around papers and pens to start writing. I stated to him the only reason I am doing this is because 1. it's in the best interest of the patient and 2. he told me to. He agrees and says he will send the tapes on to his superiors as well. We exchange goodbyes and hang up.

The woman who was sent to pick up the child's prescription is staring at me now with her mouth agape. "Wait, so Medicaid told you to committ fraud? What the hell?" "My sentiments exactly," I replied. The woman then went on a tirade and starting laughing about how she couldn't believe it but was not about to complain since the child definitely needs the medication. I agreed with her but what was I to do since I was instructed by Medicaid?

As I go to ring the woman out I ask for the patient's date of birth. "I think it's... I don't know we all have too many kids," states the man she is with. Seriously, now Medicaid patients are admitting they have too many kids!?!?! I can't believe my ears! After hearing this I half expected some hell spawn to appear from behind the pharmacy counter but thankfully it did not. The woman gave me the correct info and was glad I could help and planned on contacting her social worker.

This child had several prescription, all costing in the hundreds of dollars, that had been filled for over 6 months like this! The only way this could have happened is if somebody called Medicaid to get the override and repeatedly billed it that way. I can only imagine how many times Medicaid has told other pharmacies to fraudulently bill them in similar situations. With that being said it is now wonder why so many government programs are in the red or that Medicaid fraud is around $12.9 million. When an average guy from a small town with a little common sense can prove how there is a major loophole in a system designed by "well educated" politicians who make careers out of setting up these programs it is no wonder our medical system is "broken". Maybe if somebody high up in the Medicaid or government reads this I can get a consulting job in which they will pay me millions once I prove I can save them billions.

Mr. President Obama, I think I just got you a few more bailouts so how about...

When Trying Hard Bites You In The Butt... You Must Be A Pharmacist!

As a pharmacist there are many, MANY times that you can see a problem coming. One of those moments is when someone comes in with a stack of prescriptions. This is especially true when the said patient brings in the stack after 5pm, in which case if there is a problem you are usually stuck with nobody who knows what is going on to talk to in case there is an issue. This can leave you in quite a precarious point, do what is legal or do what is best for the patient. Rarely can you do both in retail pharmacy. This is the stuff they DON'T teach in pharmacy school!

A patient comes in with a rather panicky look on her face at ~1 1/2 hours before my pharmacy closes. The patient states to the technician that she is worried if we have enough of one medication in stock. She nervously says, "I wanna know if you have this medication 'cause most other pharmacies haven't had it in! He just got out of the hospital and really needs it!" From this I have determined that my actual patient is this person's father, who is just stabilized enough to leave a major hospital (at the point in which he has been there too long for their tastes and must be discharge ASAP so they can quit bleeding money away on him). This is not a rip on hospitals but the unfortunate truth of how insurance and mainly the Medicare system reimburses these hospitals, which is another story in and of itself.

I read the main prescription of concern and see it is for Lovenox 50mg inject one syringeful subcutaneously twice daily. Two glaring problems here: 1. Lovenox is expensive and 2. It does not come in 50mg! Or for that matter, Lovenox comes in no combination that can equal 50mg. This forces me to call the hospital which the patient just left and try to get a clarification of the prescription. Since one of the many residents at this facility wrote the prescription it is very well possible that the dose is wrong, the resident has no clue what strengths are available or somehow there is serious communications error since it is obviously written for 50mg.

So I inform the patient's daughter and call...

I get a hold of the hospital operator and briefly explain to her the situation. She says no problem let me page the physician.

5 minutes of elevator music interrupted by boastful statements about the hospital later...

"Hi, you were holding?" Obviously she has forgotten who I was or why I was holding. I repeat my problem to her. "Oh, you need the floor. Paging won't help you!" I thought to myself, well you suggested it and seemed certain I could reach the said physician.

5 more minutes of elevator music interrupted by boastful statements about the hospital later...

"Hi this (blank), how can I help you?" Again, I explain my situation and that I need someone who can clarify this. "OK, let me get you someone."

5 MORE minutes of elevator music interrupted by boastful statements about the hospital later...

"Hi this (blank), I am a nurse. What can I do for you?" Yet again, I explain the problem with the way the prescription is written. This time I explain all I need is someone to confirm that the dose is 50mg and that I can go ahead and dispense the 60mg syringe with an explanation to only inject 5/6ths of it. The nurse says, "I don't know can you do that?" I explain that is simple they can just push out the first 10mg and then inject the rest and that I had talked with the patient's daughter who understands. "Well, how does that work?" asked the nurse. I repeat my previous statement with more depth to how injecting with the style of syringe works. "Well are you sure?" she asked again. "Yes ma'am, this is a simple syringe it is not an auto-injector and is VERY simple." "Oh, well as long as it's not an auto-injector that's fine," she states. "OK, ma'am, can I get your name to put on this?" "Oh, I can't authorize that let me get you the physician on the floor."

SLAP! I could not help but slap my forehead at this point. I have now explained my problem in one form or another 3 times and no one knows what to do or how to go about approving this. Mind you this is considered a good hospital by the accrediting bodies.

3 MORE minutes of elevator music interrupted by boastful statements about the hospital later...

"Hello, this is Dr. (blank), I hear you have a problem with a patients Lovenox dose." Finally, someone who I think can help me solve my problem (which at this point I think I should have taken the easy route and just filled it with what I knew the physician wanted but in accordance with company policy have called to ensure that the prescription is written correctly). I explain my situation and the physician pulls up patient's profile and says sure no problem and that I can fill it that way. "Thanks doctor, the patient was getting worried they might not get this after they watched me talk to so many other people in your hospital who had no idea who I needed to talk to."

I then scan in the prescription and attempt to fill it. There's a problem. The insurance will not cover this medication because the physician who wrote the prescription (and the one I called to authorize it) are both residents and do not have active NPI numbers. I look online through the national NPI sites. Nothing. I then inform the patient's daughter of this problem. She then says, "Oh, that's OK. Just give them a call tomorrow we have enough to cover us through Friday!"

WHAT!

Apparently, this woman thought it was fine if she decided to make this situation and emergency and she needed it now. After watching me talk to multiple people on the phone and bust my tail to get her the medication for her father, THEN she decides it is no longer urgent. People like this are a serious problem. They have such an entitlement complex that they feel it is acceptable to act like only they matter and their problems trump everybody what everybody else is dealing with. They cause delays in the process and are really a big reason why many pharmacies, that are not terribly busy, can have longer than expected wait times.

With that being said I have no regrets for doing what I did. I did my best for what I thought was a paitent in need. Many other pharmacists would have done a similar job. I know I made others have longer wait times for what is essentially a self serving person but I did not know that at the time. This is what makes pharmacists a different breed. We are the connecting point for solving medication problems amongst multiple doctors and getting the patient what they truly need. The necessary medication. Sometimes we go above and beyond, this is our professional touch that machines will never be able to replicate

"May I Speak to the Pharmist?"

"May I speak to the pharmist about my ascription?"

Phrases like this are all too common where I work. The one good thing is that this is where a pharmacist can make some of the biggest impact. Educating and empowering patients is where I feel pharmacists can make as big of impact as actually getting patients their medication. With a estimated 9 million hospitalizations due to taking medications incorrectly (per the Institute of Safe Medication Practices) there is a lot of room to for pharmacists to help.

Some of my personal favorite moments, and a few of my least, in pharmacy come from talking to patients about there medication. I had one patient come in to my pharmacy about a month ago with 24 prescriptions all from the same medical facility. While working on his medications and doing a profile check I realized that he had just recently received a lot of these very same medication from another doctor at the same facility. To makes things even worse a lot of the prescriptions he brought in where for the same medication from different doctors. If these prescriptions would have been filled, possibly by one of the other pharmacies he also goes to, he would have been taking over 700mg of metoprolol, 120mg of lisinopril and over 400mg of furosemide to name a few.

When I approached the patient about his medications he said he didn't realize what he was taking or that he had duplicates. I quickly asked him a few more questions then explained the situation to him, needless to say he looked shocked at what I was telling him. When I got all of his medication ready I grabbed the gentleman a large pill organizer and explained to him how to take all of his medications and what they were for. I didn't want to confuse or scare him more by explaining side effects since he again, was part of the largely uneducated masses when it comes to medicine. He seemed pleased but still a little confused. I tried a little more but figured at least now he would be taking his medicine correctly if nothing else.

This was one small moment when I could definitely say I probably saved someone from one of the 9 million hospitalizations. Educating the masses can be tough and unfortunately will probably never be done fully. Although if they all were fully educated on these things I guess I would have to find a new line of work, so I shouldn't complain but rather do what I can to help.

I think sites like http://www.familydrugguide.com are a great idea. It also provides pharmacists a new place to direct patients to in times where they may be too busy to counsel. With all of the cut backs that have happened with more on the horizon this may only get worse. Sites like these can really help dumb down things and actually work as a good thing to help tie together what a pharmacist knows with what a patients wants/needs to know. This website even has smartphone apps which might be a good reference for caretakers of patients with complex drug regimens.

I can't say that a fully educated public will happen but as a pharmacist I and many others do our best to help those who need it. I am actually in the process of writing my congressman to push reimbursement for these issues and to show how bad some dispensing fees are. Every little bit helps to further pharmacy so patients can be better taken care while still providing a less stressful workplace for pharmacists

Although they may still say "askritshun", "pa-scription", "pharmist", and "that guy in the coat". Somethings just don't change!

The Dark Side of The Moon

This is just great!

Canadian Physicians? Not As Arrogant As American Physicians!

Today was Friday the 13th. Thank the pharmacy Gods its over! Patients where crazy today arguing and losing it over every little thing! Of course tons of abusers came in too. Ironically enough the minute I put in the order for C-II medications into the system 8 prescriptions for Percocet magically showed up in 30 minutes! Again, glad today is behind me.

One thing that I thought was very different today was the two drastically different experiences I had with two physicians. One was originally from and trained in Canada (she told me this) and the other was a typical American trained physician. Both physicians worked at the same institution, both are residents and since there is only one medical school in town that pretty much supplies all the residents to the hospitals in the area I assume they are both enrolled or affiliated with that university.

The first physician actually called me to make sure that her patient had a prior authorization taken care of for his prescription. This about floored me that a physician would actually call to make sure a prescription was covered for their patient before being prompted by a pharmacist or patient. She was very polite and explained that being from Canada she did not fully understand the American insurance system. WHOA! A physician admitting they don't know everything? They exist? I then checked and sure enough she was right, this patient needed a prior authorization for their Diovan. I explained what they wanted to use (a generic ACE inhibitor over and ARB) and what I would substitute for it based on what I saw in the patients profile. She explained to me that apparently the patient had a ACE-I induced cough issues several years back, which was never filled by my pharmacy. I then explained to her how to go about getting a prior authorization for the patient. The physician thanked me. Let me repeat that... THE PHYSICIAN THANKED ME! One of the few times a month this actually happens and was definitely sincere.

A few hours later the same physician personally called back to tell me it went the prior authorization went through and it indeed had. She then asked me to explain some things about American insurance to her. I explained it pretty quickly but basically they do everything they can to keep costs down and therefore increasing their profits. I went in more detail but don't want to drag on here. She was glad that I was the first pharmacist she had a good experience with and took the time to listen to her and explain a little about how I see things. I was hands down amazed at how passionate and genuine this physician was. Definitely one of the best physicians I have EVER come across.

A few hours later...

A patient came in with 5 prescriptions all for very expensive medications relating to HIV. The physician who wrote the prescriptions was a resident which in itself isn't too big of a problem considering the prescriptions actually made sense. It is very common for residents to write for medications that doses are either A. Made up, B. Way out of normal range or C. Don't make any sense to what they are treating the patient for. The one problem that occurred was that this resident was not on file and did not have an NPI number (which is quite essential these days to bill most medications to insurance companies). I called and had the doctor paged to get his NPI number since I could not find it with a few websites online.

20 minutes later...

The paged physician calls me, on his way home of all things, and tells me that he has an NPI number. I then ask him what it is. His response was, "Look it up." I explain that I tried and that nothing came up. He then spelled his name to me slowly like I was in middle school. I then told him that was exactly how I had it spelled and still nothing. The physician then said, "Well I know I have one! The paperwork has been mailed in and I got something back it just isn't on me at the moment. It HAS to be online SOMEWHERE!" How about this "doc", since you have it and I don't (and neither does the whole freaking internet!) why don't you look for it and when you find it give me a call? He agrees to this and hangs up.

An hour later...

The fairly grumpy physician calls back and repeats to me his NPI. He also gave me a website to look up his NPI and said he knew it was there. This was the same website I had previously used and explained it to him. He then decided that while he had me on the phone he was going to look it up to prove me wrong. He looked it up. Nothing. Just like I has said. The physician then said, "Well it should be there I don't know what's wrong with this site!" I decided to cut my losses and close the discussion since I had proven to him that he was indeed wrong and that I was a competent pharmacist. No need in causing more hostilities amongst our professions.

These two very different experiences made me wonder. Is the arrogance of most doctors a result of the American system and the pedestal that physicians are placed on? Is it an Americanized attitude? Are Canadians raised that much differently in how they interact and work together with other healthcare professionals? I am not a fan of the Canadian healthcare system but this physician has left me scratching my head a little. Would it actually be better for the patient to change to a system like this? I must say that despite all the craziness of Friday the 13th, this was quite a comparison of how physicians act and has really got me thinking. I wonder if there is a way for more physicians to act like the Canadian while still maintaining some of the benefits of the American health system.

Dating and Retail Pharmacy

While watching television today I saw one of the many commercials for online dating services. I know many people who use these and several people who have had successful relationships from using these sites. One major problem I can see with these would occur with people who work with the public, like retail pharmacists.

This may seem like an innocent and effective way of meeting people who are also interested in a relationship. However, when working with the public this puts a bit of a twist on things. Consider that anyone can sign up for a dating website and most of these sites let people limit the geographical area in which people can search for other singles. Thus if a retail pharmacist was to sign up for one of these sites there is a decent chance that they may see some of their patients on the dating site. Also, the patient may see their pharmacist on the site as well.

Seeing a patients profile could actually work for the pharmacist since they will see what medications a patient is on before they decide to wink, poke or talk to the patient/dating interest. However, this may also put the pharmacist in a predicament, what if they are not interested in the patient but the patient has a thing for them. Trust me, people have no fear getting flirty with their pharmacist either. They already trust their pharmacist with to handle and check things that they are going to put into or on their body. With trust already being there, the pharmacist is also a well respected and decently paying profession. Don't those sound like good qualities in a person for someone looking for a person to date?

Now, I am not saying that these websites are forbidden for pharmacists, but rather use caution when using these sites. Also, if something like this does occur, be sure to weigh all options before making a decision, for personal sanity NOT the business end of things! Besides we all know those patients who get flirtatious with the pharmacist, kind of adds some flavor to the day really. Heck, many pharmacists (who are hopefully single or in an open relationship) have gotten flirty with patients as well. One of the many perks of the job. The key and hardest part is to make sure that a line or multiple lines are not crossed. Show respect for the patient and their rights (even though they may not do the same for the pharmacist), remain professional while at work and be certain that whatever you put out on the dating site is nothing that can come back to you in the work environment. Admitting to having a leather fetish and enjoy multiple partners may not be what a supervisor or patient would like to know about but they can both read it if it's put out there.

That being said pharmacists should still do what they want but occasionally listen to that little voice in the back of their head before posting things on the internet!

Cialis... Ta-da!

Cialis is hands down the most aptly named of all the erectile dysfunction medications. This works several ways...

The generic name is tadalafil. It literally included the words Ta-da. As in, "Ta-da! It works I can now get an erection!"

I am also assuming the person who was the head researcher for it gave some insight to the marketing guy for the brand name. Taking another assumption here that the head researcher is probably male (because what woman would want to give a man another reason to have an erection) and had a wife or female significant other. Hence after he helped find the medication he probably snuck a little bit out of the lab to it home looked at his wife and said, " See Alice, it does work!"

The Retail Pharmacist's Creed

So I was watching a war movie after work and thought how relevant The Rifleman's Creed is similar to what pharmacists do. Maybe I am trying to make pharmacy too cool. Maybe I way to into war movies. Maybe I will make all the future pharmacists I train learn the lines below and put it up in my pharmacy framed.

"This is my computer. There are many like it, but this one is mine. My computer is my best friend. It is my life. I must master it as I must master my life. My computer, without me, is useless. Without my computer, I am useless. I must use my computer true. I must check faster than my patients who are trying to kill me. I must check them before they bury me. I will...

"My computer and myself know that what counts in this volume is not the volume we check, the noise of our printer, nor the smoke coming from it. We know that it is the accuracy that count. We will be accurate...

"My computer is human, even as I, because it is my life. Thus, I will learn it as a brother. I will learn its weaknesses, its strength, its parts, its accessories, its keyboard and its mouse. I will ever guard it against the ravages of viruses and damage as I will ever guard my legs, my feet, my eyes and my wrists against damage. I will keep my computer clean and ready. We will become part of each other. We will...

"Before God, I swear this creed. My computer and myself are the defenders of my patients. We are the masters of our pharmacy. We are the saviors of my life. So be it, until closing time and there are no prescriptions left, but peace!"

See, it works...

This is The Pharmer How Can I Help You?

Gotta love it when you can recognize the drug abusers by the number on your store's caller ID and when the hang up after the learn who the pharmacist is

Lost Lovastatin

**RING-RING**

...

**RING-RING**

The Pharmer: Thank you for calling the pharmacy how may I help you?

Patient: I think my girlfriend stole my medication! Can you look up when I got it last?

The Pharmer: Sure, give me one second to look up your profile...

Patient: When did I last get my lovastatin it seems to be gone?

The Pharmer: Looks like you last got it about 5 months or so ago. Would you like me to refill it?

Patient: Yeah, I'd like that. I guess I won't have to beat my girlfriend for stealing my medication now! I'm glad you got it there.

The Pharmer: Good, because I strongly advise against beating girlfriends. Thanks and we will see you in a bit

I didn't realize that someone would assume another person would steal their cholesterol medication. Let alone the idea for flogging a girlfriend for it! Guess I should have asked him if he needed his Clozaril filled too.

Pharmacy Comic

Just found this and thought it was funny!

All's Quiet on the Western Front

Today was a a very quiet day. After the absolute insanity of last week, which was the first week of the month, today seemed like bliss. It amazes me how packed the lower income area pharmacies get during the first week of the month. The crazier thing is how everyone acts when they come into the pharmacy. I think there is a very simple explanation for this...

Pack mentality.

No I am not calling poor people dogs! Rather, I am saying that when the first of the month comes around and the Medicaid population gets their monthly checks and other benefits they feel the need to use it (like the rest of us who await payday before making a purchase). Therefore they rush to spend them and stock up on things they need (or want). Thus with all of the craziness people get upset and frustrated with each other, thus multiplying the animosity felt towards others. So who to take it out on? Well when they come to a place to pick up something they need/want and are told it may take an hour or two to get it, it is understandable as to why they get upset.

The pharmacy counter is unfortunately a good place for this. Patients come from the doctor and waiting up to a month or more to get an appointment (some having just got their new health insurance for the month). Then they wait again to tell someone (or worse yet have the other person tell them) what is wrong with them. Then they leave and in the process of going to pick up their prescription have to wait again. Honestly, THIS is white coat agitation (Ok and maybe hypertension, too).

Anyways, it goes without saying that I am glad this monthly cycle is over. Today was a very quiet day in which all but a couple of patients were actually pretty polite and were thankful for my help. One of those days it feels good to be a retail pharmacist and realize that despite all the frustrations we regularly deal with we are the most visited and accessible healthcare for the public. Especially good when most of the patients say thank you and give you a smile before leaving!

Welcome!

Welcome and thanks for reading my blog! I decided to start this as many of my friends are amazed/dumb-founded/shocked at some of the things I deal with on a daily basis in my work as a retail pharmacist. For myself it's just another day at work with the public.

I am a little bewildered at how many pharmacists out there come off as jaded or angry. I will post daily occurrences at my pharmacy along with my reaction and thoughts about them. As I have many stories I will try to post daily. If I have a day off I will post some of my old stories or will give a daily thought about pharmacy or just the world in general.

Hopefully you will enjoy my postings and feel free to comment. I am a person who takes any sort of criticism well and love to learn what others think. Expression of thought can be a great tool to learn from.