Pharmacy "Discount Cards" = Point Shaving

Point shaving - A type of match fixing where the performers try to prevent a team from covering a published point spread. Unlike other forms of match fixing, sports betting invariably motivates point shaving. A point shaving scheme generally involves a sports gambler and one or more players of the sports team favored to win the game. In exchange for a bribe, the player or players agree to ensure that their team will not "cover the spread". The Gamler then wagers against the team.

- Wikipedia (to keep it sinmple)

Point shaving is illegal and it looked at as a form of corruption. It is usually collusion between sports players and bookies to make a great deal of money at the expense of others who are gambling on the game.

This is exactly how pharmacy "discount cards" work!

Think about it for a minute. A person can usually sign up for a pharmacy "discount card" for free or a very small fee. The user then brings the "discount card" to the pharmacy where it is input into the computer as insurance (on the billing end they are treated the same). The "discount card" will usually reduce the price of your medication based on what the pharmacy markup is. Since brand name prescriptions have a lower markup than generics they have a smaller discount. In most cases I have seen it reduces the out of pocket expense of the prescription to the pharmacy cost plus a few dollars as our dispensing fee.

So how is a pharmacy "discount card" like point shaving?

Simple...

The people who make the pharmacy "discount card" charges the pharmacy (in a few cases the patient) a fee for using their discount services. In many cases this fee ranges from $2 - $5, depending largely on which card is used. On average this fee is ~$3 per prescription. This may sound like a nominal fee for such a discount however; many times these cards make more on the medication the pharmacy dispenses than the pharmacy itself!

These "discount card" makers also give distributors (aka the guy who mails the pharmacy the card or is passing them out) a cut of what they make. His profit is usually somewhere around $1 per prescription. Check out this website and tell me this isn't some sort of crazy pyramid scheme! Here is a pic from the website...

That's right, the guy who made this "discount card" makes more money than I do, despite the fact that I have the product that will improve a patient's health, have a doctorate in the field of pharmacy, assume every single aspect of risk and liability in filling your prescription and even offer consultation on how to properly and best use the medication!

Over the long haul these "discount cards” cut into the overall profitability of the pharmacy. This forces pharmacies to have less tech and pharmacist hours which increases the chance of having errors occur due to increased demands on the workers. Also, by cutting into the pharmacies overhead on the prescriptions, it forces the pharmacy to raise its prices on medications to try to recoup the loss of income associated with filling these prescriptions. Eventually this price trickles over to everyone else as well. Granted most insurance companies are protected due to negotiated prices. The person who really gets hammered is the cash paying patient who has no insurance or "discount card". I promote being your own advocate as much as anyone, but this is really a case of punishing the wrong people: The pharmacy workers and the innocent cash paying patient!

So here is the direct comparison:

Player who shaves points = Patient with discount card

Bookie who makes a lot of money = Pharmacy "discount card" supplier and distributor

People who are scammed by betting = Pharmacy staff and other patients.

The main difference here is that the patient with the "discount card" usually does not know how these cards truly work. Therefore, I must say they are not at fault and I am not blaming them. It's just a shame that the person who gives out these discount cards can make so much money! I must say, I have seen some cards that are handed out by a local county that they either don't take that much of a fee or any at all. I have less of an issue with these cards as they appear to be more altruistic.

All of this points at a big issue in the retail pharmacy industry (and healthcare in general), the need for clearer pricing and compensation guidelines. There will be a post to follow on that at some point, however if we had clearer standards the industry would benefit as a whole. Unfortunately, businesses prefer to do whatever it takes to draw patients in so they can sell them items with higher markups than prescriptions such as soda, OTC diet pills and candy bars. This results in many of them taking these discount cards and over working there associates in a cut throat fashion to make and extra dollar while not truly worrying about patient care.

I encourage everyone to do some research and see who is REALLY getting paid when they pick up their prescription...

Why Can't Pharmacists Prescribe?

I have long wondered to myself, "Why can't pharmacists prescribe?"

The immediate answer is usually "Well they dispense medication and the physician prescribes them. It's always that way, checks and balances!"

It is hard to argue with a system that has been in place for such a long time, but really ask yourself "Why can't the medical professional who is the most focused on medications not prescribe them?" Doesn't that make some sense? If nothing else at LEAST the pharmacists with PharmD degrees have enough education to prescribe, hence why it is a terminal degree in medicine.

To me it just makes sense that an MD or prescriber would write a diagnosis on a prescription and a pharmacist would then select the correct medication for the patient based upon the prescribers diagnosis. Just include all patient labs with the prescription and I can easily come up with a good solution. That is the whole point of earning a PharmD degree (yes the D stands for doctorate!). Many times a day I have to call a prescriber's office to get a medication switched to something else for a variety of reasons. Never mind the amount of times I have to call due to drug interactions or another circumstance in which I give the prescriber my personal opinion on which medication would work for the patient. Doesn't this mean I am basically prescribing for the patient anyways?

Most MD's will admit that even though they know medication they do, to some degree, rely on pharmacists to a good extent. Personally, I catch, on average, 4 significant drug interactions and 8-10 people who are abusing, in some fashion, a controlled substance. On a daily basis I also see upwards of 25-40 patients a day who are not taking their medication correctly or run out of medication while waiting to hear from the physician, nurse practitioner or whoever else prescribes their medications. Many times this is because of cost issues, insurance prior authorizations or wait times to see the prescriber.

With so many patients who are not taking the medications or not taking them correctly, why can't pharmacists use their professional judgement to prescribe a similar medication that is less expensive, is easier to use or cover the period until the patient can see their prescriber? This is a minimal level of prescribing that can save an untold amount of money to the health care system, save the professionals the cost of time dealing with these issues, improve patient adherence and improve overall health care?

Recently there was an article published by the New England Health Institute (NEHI) that reported how non-adherence to medication costs $290 billion to the United States. (Link)

$290,000,000,000!

That's almost equivalent to what the United States spends on medication, which is $307 billion. (Link) That's a lot of wasted money! Money that could be saved by simple adherence to a drug regimen. Even if measures to improve drug adherence cost $100 billion that still saves $190 billion AND improve the overall healthcare provided.

I feel that pharmacists should be able to prescribe if nothing else in a limited role that could help improve healthcare and save money. A pharmacist can note if a patient is not getting their refills on time and counsel the patient as to why. Taking this into consideration the pharmacist could prescribe something that might work better for that patient. Even if a medication costs a little bit more but improves compliance (such as metoprolol ER versus metoprolol) the cost would improve the patient compliance and improve outcomes down the road, thus saving money overall.

This limited prescribing could also lead to changes in some brand name medications to alternative generics or switching a medication entirely if a patient complains of side effects that are limiting the daily activities or causing them other issues that warrant attention. In many cases, does a patient really need to see a prescriber just to get a medicine like naproxen 500mg or to get a prenatal vitamin? These simple medications could be addressed by a pharmacist very easily. All we need is the ability to bill for our services. This charge would be less that MD's and on par with most nurse practitioners, while increasing access to care from an equally qualified practitioner.

The major issue here is communication with the prescriber, which would require some sort of notification sent from the pharmacy to the physician.

Some people may say that medication therapy management (MTM's) is the same thing, yet many physicians who I have either talked to or worked with feel that MTM's are a way to micromanage their practice. MTM's also don't address the urgency that some patients may need or the waiting time to see the prescriber. Personally, I like the idea of MTM's but really feel there needs a prescribing aspect to them to make them excel.

A point that people may point at is the potential for a conflict on interest by the pharmacist to prescribe medications they make a higher profit from. This is a legitimate concern, however, most insurances have prior authorizations in place to stop the use of more expensive medications. If a pharmacist couldn't get these medications covered, they would defeat the purpose of their prescribing role, which is to save money. Also, most generic medications result in higher profits for pharmacies due to the lower cost, hence this is another incentive for pharmacists to prescribe generics. The system already has measures in place that would help pharmacists focus on providing optimal care while keeping the cost of medications low.

Another thing that I find ironic to my point is the hospital system. Many pharmacists will switch medications to similar ones in a hospital because the medication the prescriber wrote for is not on formulary. Wait, isn't that similar to limited prescribing? Why can't all pharmacists do this? Isn't this just further validation of the point that pharmacists should be able to prescribe, especially since it saves money?

Let me also clarify that I am not advocating for pharmacists to replace physicians, especially specialists. They clearly have an important role in providing healthcare. I am advocating for expanding the practice of pharmacy as a way to decrease total healthcare expenditures while improving care. Isn't that one of the major focuses by EVERY political party right now?

I am extremely interested in feedback on this and look forward to hearing from others on it.

Why Listening Goes a Long Way

Some days in the retail pharmacy setting can be tough. We see patients who are frustrated that they have to be taking medications that they may hardly see the benefits of or must take just to survive. Sometimes these frustrations boil over at the pharmacy, particularly when there are insurance issues. Then there are those patients that are just down right disrespectful and rude to everyone, yet for some reason they always come back to the same pharmacy. I have yet to understand what drives these people to act this way and then return time and time again. Maybe it's trust without respect. Maybe it's convenience or price. Maybe it's just a routine. Maybe it's something deeper...

During the holidays it can get a bit busy around a pharmacy as everyone prepares for weekends of travel or for the pharmacy to be closed. A few days before Christmas was a normal pre-holiday rush at the pharmacy when I saw a familiar gentlemen and women come up to the counter. I waited on them as I would any other patient and saw that the 12 prescriptions they were dropping off were for one of my patients that is a real pain in my backside. Every time this patient comes in he is always cursing at the pharmacy staff and yelling about how incompetent we are, even going as far as to yell at us about his "outrageous" copays. The only outrageous thing here is the utter disrespect this man has for people who are trying to help him, including his physician he commonly lets a tirade off about.

I politely tell the man and woman that it would take a little bit to get these prescriptions ready as we were fairly busy. They asked how long and told them to give me about an hour. I hated to tell such polite and courteous people this long of a wait but there was no way it could be done any faster given the amount of prescriptions that needed to be worked on. The couple said that would be fine and they'd go look around the store.

2 hours later....

The couple comes back to the pharmacy counter and asks if the prescriptions that they dropped off were ready. My technician quickly informs them that I am finishing the last one and if they step to the side he'd be with them as soon as they were ready.

To be honest the prescriptions were not done at all. I had gotten tied up on the phone with an insurance company that killed my wait times, even though I was still checking and filling prescriptions while I was on hold or talking to the insurance agent. Nonetheless, I quickly finished checking the medication for the couple, knowing it was very important for them as well as VERY expensive. Add to this the fact that they were so patient despite the fact that it took me twice as long to finish the prescription as I had told them and I truly owed it to them to expedite the process of finishing their prescription.

After I finished the prescriptions and was printing the leaflets, I took note of the relatively high copays. The copays were somewhere in the range of $350. That's roughly a $30 per prescription copay and some of the medications weren't very expensive. The catch was the copay on the medications for the kidney transplant the patient just received (tacrolimus and mycophenolate mofetil) was rather high. I assumed these high copays were correct given the actual retail cost of this medicine was around $4,000 and just told the tech to mention this to the patient. It wasn't like they could really say no or not take this medication for the patient, he needed it to accept his kidney and go about life!

The patient couple was called over and informed of how much their medication was. Immediately the woman looked at her husband and said, "We can't afford this! I don't have this much in my checking account. (Insert real patient name here) only gave us $25 and said that would cover it." The husband responded gruffly then called his credit card company to make sure he had enough credit limit left to charge these medications.

At this point I couldn't help but feel for these people. They were going above and beyond to take care of a patient who I knew full well was a handful. I could only imagine what they were going through and how he was treating them. I quickly walked over to the counter and explained the actual cost of the medication to the women, as well as why the patient needed them.

This is when the water works started...

"I know they're expensive and I know it's not your fault, but it's just we are here from out of town to take care of my brother who just got a kidney transplant. We found out a few days ago that they found a donor for him and that he would be getting this kidney, so we drove up here on a moment's notice and helped take care of him and his house.", she said through what was beginning to be a full on tear-fest. "We have been up here several times over the past year, each time dropping what we were doing to take care of him when he got admitted to the hospital. We just want him to be healthy but all he does is shit on us!" The tears were really coming now.

Knowing how verbally abusive this patient can be I try to calm the woman down, "Well, ma'am I know how he can be. He has given us a tongue lashing or two in our time with him." as I nudge my tech, "However, ma'am you and your husband are doing the right thing. You're trying to help someone and if no one else tells you that, trust me, you're doing the right thing and that's all that counts."

The woman leans over the counter, still sobbing, and hugs me (a little awkwardly as the counter is at least 2-3 feet wide). "Thank you so much! It's just we have cleaned every inch of his house! There was rat turds and trash everywhere! We scrubbed the grout with Ajax and bleached everything! We are constantly funding his healthcare and trying to work with him and he won't even quit smoking! He lied to them and said he stopped but he even still drinks a couple beers every day! Now I'm stuck here thousands of miles from home with my brother who doesn't give a shit, no money and all I want for Christmas is to be able to go home!"

I couldn't stop hugging this poor woman. I was so backed up that I probably wasn't going to leave for at least an hour after my store closed but I couldn't stop. This woman wasn't even my patient but after seeing how a similar situation occurred in my family a few years back, I just couldn't stop hugging her. She needed it. Even if it was from a completely random pharmacist.

She sobbed some more and went on how she doesn't want to lose her brother because he won't follow any of the medical advice and he is even thinking about getting some puppies to make himself feel at home (this is kind of a big no no if someone just got a transplant seeing as how dogs are the cleanest animals). She went on and on for a while even her husband, who was clearly the rock in this relationship, was getting watery eyed as he saw me start to tear up knowing exactly what this family was going through.

After a few more minutes of sitting with this woman on the bench in my waiting area while her husband paid for the prescriptions, I counseled them on what each medication was for, how to take it and gave them a complimentary pill organizer that would help them organize her brother's medications while they were there and hopefully afterwards.

Mind you I was in my lab coat and in full view of other patients who were waiting. Not one of them said anything or even huffed over having to wait a little longer as I worked with this woman and her husband.

After counseling it dawned on me that there was a local kidney center that could help take care of patients like this woman's brother. I looked up the information on my smart phone and put it on the back of my card, that way she or her husband could put it in their wallet to call later and help set up care for her brother. I explained that maybe this could save them from having to come back so much or even at all. This is when the woman blurted out through the slowing tears, "Thank you so much! My brother always says how good you all are here. I just feel like you're an angel that was sent to help us get through this!"

Whoa! I have been called many things as a pharmacist but an angel is NOT one of them!

I jokingly played it off, thanking her and telling her "That's funny you say that because you brother has called me every four letter word in the book before, it must be how he shows love." The woman laughed and hugged me again. Her husband firmly shook my hand with both of his big callused hands and said, "Thank you so much for listening, it really means the world to us."

As they left they took my name and asked for the name of my district manager, as they wanted to call to tell him what I had done for them. I gave it to them (as these calls NEVER happen) and said I appreciated it. The woman replied, "Well we appreciate everything you have done for us. It's the least we can do since you gave us a Christmas miracle."

I was able to help 3 people, maybe more. And all I did was listen...

The Scary Future of MTMs

If you have been listening to the recent news and trends in the pharmacy industry any time in the past few years the chances are that you have heard of medications therapy management programs (MTMs or also called MTMPs).

"Medication therapy management, also referred to as MTM, is a term used to describe a broad range of health care services provided by pharmacists, the medication experts on the health care team." - APhA

MTMs were first mentioned in the Medicare reform under President George Bush and have shown to decrease healthcare costs significantly as well as show increased patient compliance and overall improvements in healthcare quality. MTMs have a big role in the future of pharmacy and could really develop a new face for the profession.

There is one key thing to all of this, however. MTMs must be performed in the right way, with physicians and patients who are open to the concept. This way the programs can have optimal results and show other professional and members of the public the benefits of having a pharmacist perform such activities.

I recently found out, through a source not to be named, that a major chain pharmacy is rolling out an "MTM" program. This program however is being done in a very poor manner. The chain is trying to force all of their pharmacists to participate, even those who are older and not fully up to date with current practice guidelines. This chain is also having pharmacists call physicians office and recommend adding/changing medications, which may sound like a good idea however, these pharmacists are doing so with no lab work, no practice agreements with physicians or with patients and nor formal training in how to run or operate and MTM program!

The practicality of this chain's "MTM" setup is just atrocious. How many physicians are open to a pharmacist (or anyone) calling them and recommending they put their patients on more medicine or changes in dosages, outside of the normal calls that occur already? How many patients really want to be on more medications? From my own experience both of these issues provide serious obstacles that I do not see going over very well for the pharmacists involved.

The main problem here is greed. This chain is not reimbursing their pharmacists any more for their time spent performing MTM services. They are forcing them to do all of this on top of giving flu shots, filling the same number of prescriptions (if not more caused by the calls they will be making), answering phone calls, counseling patients and any other duties that need to be performed. This chain has held stagnant is sales while others have increased over the same time period, thus they are trying to increase business by forcing pharmacists to make more phone calls. I am curious to see if the chain will also try to bill insurance companies, particularly Medicare, for these MTM services and how successful they will be in doing so. Let us not forget that all of this is also occurring after this chain cut both pharmacist and technician hours. YIKES!

Another thing that worries me here is the lack of cohesion that this may cause in the pharmacy industry. Accrediting bodies have fought long and hard to get these type of programs set in place and reimbursement for these services, which is great! They have also established residency programs with the specific focus of MTMs and have recently established a board certified program for these types for these types of positions. This chain is single-handedly degrading everything these bodies have worked for by having under qualified professionals perform these duties.

Now, before everybody thinks I am demeaning MTMs I must say that I am in full support of MTM programs and really believe that they are a great thing for pharmacists to be involved in. The provide a great benefit to both the patient, the payer and the healthcare system. That being said, they should be done correctly and rolled out in a manner where all participants are accepting of it. It should not be forced on pharmacists, physicians and patients like this chain is essentially doing.

The problem here is a simple one to me. Too many under qualified pharmacist will be forced to execute MTM services in a poor manner. This could potentially lead to resistance to it's acceptance and eventual adoption into the healthcare system. This would be greatly disappointing because of the potential delay in improved healthcare, education and substantial money saved. I would love to see these types of programs rolled out over the whole U.S.A., I believe the way to do it is start in a manner that will be better accepted by all participants. A suggestion of mine would be to start in smaller areas where pharmacists, physicians and patients all, generally speaking, know each other a little better. This much has already happened to some degree, seeing as how many independent pharmacies currently provide these services. The chains need to start in a similar fashion and be sure to include such services in a manner that takes pressure off of the pharmacist so they are performing these services while prescriptions and other duties are piling up on them. This may mean that one pharmacist has to cover a few different stores until the program is more widely accepted but at least a properly trained professional will be focused and undistracted from what they are to do. This is an idea the previously stated chain is clearly not concerned about.

The biggest thing here is that pharmacists need to step up and show what they can do, but stop trying to be Superman and do everything all at once, which sadly is what we are known for doing. I would love to see MTM services rolled out in a greater scale but I am afraid if not done correctly it could cause years of delays in acceptance and costing this country a lot of money in several different ways. I hope this chain realizes their soon to be potential misstep and really thinks about what they are doing. The problem is stock prices and greed may win out.

(Note: I have left out several citations for fear of fully divulging which chain this is. Any comments left after this are not mine and that of individuals who do not speak on my behalf.)

Are You Still A Pharmacist?

When I tell people I am a pharmacist many people picture me working behind the counter of a local retail pharmacy working at a computer station while on the phone and maybe counting pills too. Some people consider this to be a cushy job. Retail pharmacy has no real physical demands and a good salary. Heck, another health care professional writes a prescription and the pharmacist reads it and fills it.

This perception is partially true but there is much more to it.

Many patients don't fully understand the amount of interactions that pharmacists perform on a daily basis. I counted myself how many interactions I made in one 40 hour work week, there are as follows: 22 refill too soon interactions (10 were due to patients wanting controlled medications early and 12 due to patients getting refills on medications they did not know how to take properly), 26 drug changes (10 due to drug interactions that could result in serious side effects, 10 due to cost concerns for the patient and 6 to provide more optimal drug therapy) and 11 prescriptions where changed due to dosage/frequency concerns.

These changes did not include issues that insurance companies prompted me to correct. These where changes I made as a pharmacist. These where changes that helped improve health care for my patients.

With all of this contact amongst other professionals including mostly physicians and nurses you would think they would realize what retail pharmacists can do? Realize the importance of having that final set of knowledge, training and eyes brings to the table, right?

Many of them do, then there are stories like this...

My intern came to work one as usual since he is now a a month break in between rotations. After I got done explaining to a nurse why the physician needed to switch medications for a patient, I hung up the phone, turned to my intern and said, "Sometimes I am amazed and that I have to explain myself in such detail to other people in health care."

The intern looks and me and says, "Well, on my last rotation I told a nurse I wanted to do retail. She then asked me if I'd still be a pharmacist. I explained to her yes I would still be a pharmacist, I'd fill prescriptions and make drug interactions and give patients their medications while counseling them too. She didn't get what retail pharmacists do. She honestly thought we just threw pills into a bottle and that was it. She didn't get why I needed a doctorate to dispense medication. She had no idea what pharmacists do or that we actually did anything. I got kinda mad at her and no matter what I said she just had this close minded idea about pharmacists:"

I can almost see a construction worker thinking this. I can almost see a pastor thinking this. I can almost see the normal little old lady (an L.O.L.) thinking this.

I can NOT see a nurse thinking this!

How can another health care professional be so ignorant to what a whole class of medical professional does!

This is the equivalent to me talking to a nurse and saying, "I thought all you did was walk around in scrubs, jot down my blood pressure and gossip with other nurses in the hallway. Any knuckle-dragger can do that, right?"

Now before the nurses I know jump down my throat, I know all that you do. I know you usually double check even my work as a pharmacist, help physicians by describing what the patient has been up to and reacting to, all while taking care of the patients basic needs and address their many concerns. I know you do even more than that. Just like pharmacists do many little things that are in the best interests of their patients that are also too numerous to list.

Just today I had a patient who was very concerned about their mental health. He was a diagnosed manic-depressive who was on Zyprexa and Seroquel but has been getting more depressed recently. I asked him a few questions before getting out of him that he hadn't been on his prescribed Celexa as well. He mentioned that he must have forgot to get it refilled and when asking a few more questions it became apparent that his depression had been increasing for over 4 months, the same time frame he had been off his Celexa. I suggested he refill it then let myself and his physician know how he was doing in a month or so. He was more than thankful for my time and was certain that this would help. Now I can't say if it did or didn't help as it is too soon to tell but by explaining what I knew and understood this man was appreciative and understanding. What else could I do as a pharmacist?

This is why I make sure to do my best to fully explain to everyone what it is I am doing or did for them. This includes physicians, nurses and especially patients. The degree of explanation varies with who I am talking to but nonetheless I still explain. I feel this helps instill confidence in both myself and my profession. Every pharmacist should do the same to the best of their ability. It is part of the reason pharmacists were the #1 trusted profession for so many years. As the most accessible health care professional it is part of our duties. It is what will help patients and other professionals recognize the importance of our role and realize that we are not simply robots dispensing medications. We are needed professionals who bring a different perspective and knowledge base that can help ensure optimal medical treatments as well as keep costs down. Good pharmacists are always in need even if we are in retail we can still make a big difference, as much as any other health care professional. Without us patients wouldn't get their medications, there would be more medication errors and the health care system would be far worse than it is even now.

This is why I am a pharmacist!

When A Medical Professional Turns Into The Patient...

I woke up the other morning with pretty badly irritated eye. Apparently I forgot to take my contacts out before going to bed. WHOOPS! I walked into the bathroom and looked into the mirror just to see how seriously red my eye was. I decided to take my contacts out, not sure whether it would make the situation worse or not. It made it worse, much worse! My eyes had a sharp stabbing pain whether it was open or shut. I continued to cover and wipe my eyes of drainage and decided to lay down and see if it passed. This did not help very much so I got the idea to put some contact solution into my eye in hopes it would bring some relief. It only stung more.

I guess I had to go to the pharmacy to see if something like Clear eyes or Visine would help. I figured that if this didn't do the trick, I might have to get some further medical attention that was above my own skill as a pharmacist.

The pharmacy I went to was the one I currently work at. I called a friend and he went with me in case my eye really bugged me. I made it to the pharmacy, picked out the eye drops I had in mind and left. My friend drove me home and stuck around to make sure I was alright. Thank God for good friends. The eye drops burned and did not seem to help much. I waited awhile and tried them again still to no avail. It was time to seek further care.

My friend drove me to an Urgicare which I used to know some nurses at. When we got there I had to fill out 4 forms and give them my insurance and identification. Filling out forms with one hand over your eye is not the most fun, especially after a 20 minute car ride which simply looking out the window makes you nauseated. I turn in the forms and waited to be seen. I waited about an hour and fifteen minutes in the waiting room before being called back to an exam room. Finally!

Once in the exam room the nurses came and asked some basic history and pain questions. They also took my blood pressure and they took it wrong. They raised my arm just over shoulder height and took it. Blood pressure readings should be done at heart level, at least that's what they taught me. I then continued to wait 45 minutes for the physicians to come into the room. He explained what he thought it was (since I gave a very detailed explanation he probably could have diagnosed it without even seeing me) and what he was going to do to examine it. Overall, he was very professional and I was pleased with his work. He then explained he did not see anything serious but was going to give me and antibiotic just to be safe. I then told him I was a pharmacist and wondered what he was thinking for an antibiotic. He said I should have mentioned it earlier and said he was going to write for Vigamox.

Wrong answer.

I knew Vigamox is over $100 a bottle and requires a prior authorization for every insurance I have every dealt with including my own. I suggested tobramycin and explained to him what I knew. He agreed and appreciated my knowledge then left to write the prescription. He came back and gave me follow up instructions if needed, including an ophthalmologist he knew personally, as well as the prescription for tobramycin eye drops, then showed me out to the nursing staff to sign one more item.

When I saw the nurses and signed their document, I asked them to call my prescription into a pharmacy near by that was part of the chain I work for. They were hesitant and said they do not do that.

Wrong asnwer.

I told them I am a pharmacist and that I knew the pharmacist they would be calling it into. They checked with the physician who literally said, "Ya, why wouldn't we call it in?" They agreed and I left with my friend to go to the pharmacy.

We got to the pharmacy 30 minutes prior to close and to no surprise my prescription was not ready. I asked how long and the intern, who I knew, said that the pharmacist did not take it because they were out of stock of it. Personally, I would have still taken it and then offered the patient to transfer it, but to each their own. The pharmacist said the Urgicare was going to call me to call another pharmacy with it or to preferably to pick it up. One problem, my cell phone was dead. Thankfully, my friend let me use his phone to call the Urgicare and call it into the exact pharmacy I work at, to which the Urgicare nurse obliged.

We drove to my pharmacy, speeding a little since we know we would be getting there with in 5 minutes of closing. I called ahead as we pulled off the highway and my pharmacist partner said it was ready and he would stay open until I got there and that he rushed it since he knew it was mine. Again, I am thankful I know how the medical system works and some people in it, which allowed me to get my prescription in a fairly timely manner.

As I was rung out by my cashier, I thought to myself, "What if I wasn't a pharmacist?" This would have meant that the doctor would have written for an expensive prescription which my insurance wouldn't have covered. I would have gotten to the first pharmacy and been pretty frustrated since I had spent 2 hours plus at the Urgicare and still had a sore eye. If the pharmacist would have called the Urgicare to change the prescription, she would than have not had the antibiotic in stock. I then would have to go to another pharmacy to get my prescription. I also would not even be able to stay with the same chain to get my prescription that night since they all would have been closed. I may have even not gotten my prescription that night. On top of all of this the antibiotic I did receive needs to be applied every 3 hours while awake. This is fine by me, since it was $4 instead of over $100, but even as a medical professional applying an eye drop every 3 hours is hard to remember. Imagine if I were a patient again, I would probably be annoyed and not understand why the drop needs to be used so often.

This whole experience really did make me think differently about patients who come in last minute. Ironically enough I had a patient about my age come in with an antibiotic 5 minutes prior to close while I was already busy the night prior to my eye injury. I told him to stick around as I would make sure he got it before he left. The man was grateful for my services and that I took care of him despite being busy. I now fully appreciate his appreciation for me taking care of him despite the fact that I was closing really soon. Thankfully, karma must have paid off and taken care of me when I needed it. I can definitely say I look at the last minute patient with a little bit more respect considering what they might have just been through. If a last minute patient just hurried to make it in, I will definitely take care of them as long as they are in a true urgent need and not just filling a prescription they had for 2 weeks. This is especially true if a patient has an antibiotic or is from an Urgicare!

Why Herbals Are So Popular

"Is there anything over the counter I can take for my menopause?"

"Where's your glucosamine at?"

"Can you recommend something natural?"

These are some very common phrases around most retail pharmacies these days. Many consumers are turning to herbal supplements to help them improve their health or to aid them in other ways. This boom in herbal remedies is due in large part to the amount of information available on the internet and the ease of access it provides now more than ever.

On a daily basis I have handfuls of patients that ask me question pertaining to a variety of health issues and remedies for them that they have researched on the internet. In many cases, these patients come to me asking what I think about specific products and "do they work" or "how well do they work". With the availability of information many of my patients can filter out their symptoms and essentially find their "diagnosis". I use that word loosely since only limited medical professionals can actually make a diagnosis.

To be fair to lay people, I put myself in their shoes...

I am sitting at home with knee pain and wondering what I should take? Should I take the Celebrex (celecoxib) the physician prescribed for me? I just saw a commercial of which half it was the risk of side effects including possible heart issues (by law 1/2 of all prescriptions advertising must be focused on things such as side effects, just look at the next printed medication ad you see in a magazine). Well that seems a little bit serious. I remember there was a commercial for Osteo-Bi-Flex when I was watching the price is right and it didn't list any side effects. No side effects must mean that it's safer, right? There was also a commercial for One-A-Day Energy which said it would give me that little kick I needed. I am going to go the the drug store...

After arriving at the drug store, I grab a generic pain reliever (that is similar to Celebrex but cheaper as my pharmacist said) and what appears to be a generic for Osteo-Bi-Flex. I look at the labels...

First the herbal supplement...

Just like I thought, there aren't very many warnings. Now let's look at the over the counter (OTC) pain reliever...

WHOA!! That's a lot of information on a bottle about the same size. I think I am going to try the herbal instead. Let's look at the energy vitamin. It looks like the rest except it has guarana with an asterisk by it. It's probably alright...

Now this is in now way an all encompassing example. Many of my patients will actually listen to what I recommend for them, especially if I tell them it's what I would take if I were them. However, there are also several patients a day that now matter what I say they believe that the natural is better. I do what I can to help all but sometimes, they will not simply listen.

With such strong FDA restrictions on prescription and some OTC medications while have little to no regulation over herbals it is no wonder why advertising and the billion dollar herbal industry has lead consumers to think they are much safer than FDA tested and regulated medications. Many patients, even when they look up herbals on the internet, are not aware of the side effects or drug interactions of many herbal medications or that many of the herbal products are not tested and in many cases are not regulated for quality.

Just to highlight a few common areas I see in a daily basis I will keep this herbal review short. VERY SHORT. Here are some herbal basics:

1. ALWAYS consult a pharmacist/physician before taking them. At the very least do some homework and look up possible indications and directions for use as well as potential side effects.

General Rule: Beware of the G's - Ginseng, Guarana, and Garlic. These have the most interactions and the first two can increase blood pressure signigicantly. Glucosamine is generally safe but may interact with Coumadin (warfarin)

2. If it makes some cure all or miraculous claim, it's garbage and will not live up to the hype

This includes: most weight loss remedies (Alli will work but with proper diet and exercise only minimally), male enhancement or erectile dysfunction (ED) herbals (some with yohimbe or horny goat weed may work but all of them I have seen have ingredients that will raise blood pressure which may worsen ED), and colon cleansing products to name a few.

3. A lot of the herbals have some basis as to why they work. However, many may only work mildly if at all. They are not replacements for prescription medications.

4. Look for the USP or ISO certification stamps. These mean these herbals where tested by an independent third party and actually have what they claim in them. Thus these are safer than most.

5. Do not ask advice at a store that strictly sells these products. Many of the employees have numbers they need to reach and will sell you a variety of things to meet THEIR NEEDS, not yours. Instead ask a health care provider, like a pharmacist. We must be able to legally back up what we recommend. Would you trust someone who must back up their recommendation in a court of law or someone who was hired last week and is still in high school?

With all of that being said herbals are not always a bad thing and can actually help many people live better lives. They are not cure alls but should be used with the same discretion as prescription medications. Everything has side effects even foods. If a person eats too much fat, they gain weight. BOOM! Side effect! Always ask advice of a professional. Yes, they may make a little bit off of selling you something but they are held accountable for what they tell you. That's why they are PROFESSIONALS!

15 Pharmacy Rules for Patients

Pharmacy Rule #1: If your name looks like a set of Scrabbles tiles don't yell at me if I butcher it.

Pharmacy Rule #2: I can only explain your insurance only covers 30 days worth of medication instead of 90 in so many ways before I give up. I am not bad at dumbing things down, you may just not be that intelligent.

Pharmacy Rule #3: If you don't know the date of birth or address for the prescription you are picking up, I do not know how to sell it to you. Double checks are there for a reason.

Pharmacy Rule #4: If I tell you your refill is too soon and you try to have it transferred to a different pharmacy, I will make sure the other pharmacist knows it's too soon and that you are a current problem for me. Therefore they won't fill it either.

Pharmacy Rule #5: If you try to get you pain medication filled too early repeatedly you will get a nice note in your profile that will let other pharmacists know this.

Pharmacy Rule #6: Respect. Respect the pharmacist and the technicians. Respect is mutual and if you don't respect us, we will not respect you.

Pharmacy Rule #7: If you do not think something is correct please feel free to ask. If you do I will look into it and try to correct and problem willingly. If you yell and make a scene, I probably will not go out of my way (unless it's truly bad).

Pharmacy Rule #8: If you simply say thanks or show that you appreciate my work, I will bust my hump for your gratitude and take care of you.

Pharmacy Rule #9: If I can't read it, I can't fill it. I will try to clarify any issue, unless you act indignant towards the fact that my effort and care may take a few more minutes to ensure YOU get what YOU need.

Pharmacy Rule #10: Your physician isn't always right. Neither am I and neither are you. Everyone's human, so there is no reason to go crazy about something if it's small. If it's big bring to my attention as politely as possible and it WILL be resolved.

Pharmacy Rule #11: Controlled medications are controlled for a reason. This is why I can not fill them early. Drug abuse is real and very serious. No early controls. Period.

Pharmacy Rule #12: I see more patients than any other medical professional and do it fast and accurate. If I need extra time to ensure something is correct, please allow it. It is YOUR health.

Pharmacy Rule #13: If you think my hold time sucks, feel free to call your own insurance company. I do it all the time for YOUR gain, not mine. Trust me it sucks 5 times worse.

Pharmacy Rule #14: There are many pharmacies and pharmacists out there. If you and I don't get along or see eye to eye, feel free to venture elsewhere for BOTH of our sanities.

Pharmacy Rule #15: I became a pharmacist to help people. I did not go through 6 years or more of college, stay up countless hours studying and busting my hump to be a pain in your side or to play God as some may accuse me of. I use knowledge, legalities and logic to ensure what I am doing is the best for my patients and others. This is why I am a pharmacist.

That is all of my pharmacy rules for patients.

Until I can think of more.

Fried Chicken with a Side of Diabetes

Any time I see a patient in motorized cart headed towards my pharmacy, I can usually see some sort of odd problem on the horizon. When the patients pulls up in a motorized cart, is over 100 pounds overweight and eating fried chicken straight off the bone (grease all over the prescriptions of course), I know it's going to somehow cause me a headache!

A morbidly obese patient slowly heads to my pharmacy in a motorized scooter because they are probably too large to walk any distance. They hand my technician several prescriptions with one hand while eating a few pieces of fried chicken in the other. My first thought is that that all of these prescriptions are probably for diabetes and hypertension and of course they were. Clearly this patient is not trying hard to control either by eating fried chicken for a snack (it was mid afternoon and I am sure she does not miss many meals) and not even trying to do simple exercise like walking.

The technician tells the patient that it will be just under an hour to get their prescriptions ready because there are so many of them and it is the first week of the month, so we are swamped. The patient scolds the tech with, "I can't believe this I need my medicine and I have to wait and hour!?! I am gonna go over there and I'll be back in half an hour they better be ready!" The tech tells the patient that she is welcome to come back but it will be closer to an hour. The patients scoots aways with the drumstick still in her hand.

Twenty minutes later, I finally am able to initially check the prescription before the techs fill it. I do so and then my computer tells me that her insurance won't cover the medication because the physician did not put clear and precise directions or a diagnosis code on the prescription. Although forgetting this legal bit of info to bill a government insurance, which the physician knows the patient is on, she did put her hemoglobin A1c which is 11.0. This measure is explained here. Despite being on high doses of every medication possible this patient's diabetes is still through the roof! Again, reinforcing my previous opinion that she really does not care but is rather riding this for what she can get out of the government.

Like any good pharmacist, I pass the task of calling the physician's office on to my intern. My intern calls and actually gets a hold of the physician. Odd, why can I never reach anyone of knowledge when I call that office? He explains to her the situation and the response by the physician is appalling. "This has happened before and your pharmacy always prevents my patients from filling their medications! It's only you guys! Just give her the damn medicine and don't bother calling me back! I have other patients who need help too and I am sick of you calling me on technicalities!" My intern looks at me with a look of disbelief, he knows I heard the whole conversation because it was that loud.

Now I am angry. People don't like me when I am angry...

I call back and get the office secretary and ask for the physician while explaining where I was calling from. "She's in with patients can I take a message for you?" I explain that I can hold it's that important. After several minutes on hold the physician picks up the phone. "How can I help you?" It's go time! "Hi, is this Dr. (protected so I don't get sued over slander)? It is? Good, I have to tell you to NEVER treat an intern, or pharmacist for that matter, like that again! We called you because you did not fill out a prescription in the correct and LEGAL way so we can help one our mutual patients! I heard what you said to my intern and am tempted to report this further to the institution you practice under. Are we clear? GOOD! Now can you get me the diagnosis code and the precise way she is taking her medicine so I can give her the DAMN medicine you prescribed? Uh, huh. OK. Thanks! I appreciate you giving me that LEGAL information. I hope when or if I have to call your office again your are more appreciative of what I do. Without my knowledge and skills your patient would not get their medicine and good medical care could not be provided. Have a great day!" **CLICK**

At this point my ears are red and my intern is in hysterics. It is sad how some people, particularly in medicine, have such a God complex. Now the patient is at the counter and asking why her medicine isn't ready. My intern quickly walks over and informs the patient who promptly starts into a fit of yelling. My intern is calmly explaining the situation to the patient but the patient is not listening. I don't expect patients to fully understand everything but I do expect that they listen to me or trust what I am doing is correct. They can even question me but there is never any reason to yell unless something is really messed up.

I scurry over to bail out my intern. As I start to tell the patient what all we had to go through to ensure that they get their medicine they shouts this, "I don't care! My doctor gave me those scripts and there is always some problem! I ain't waitin'! Let God figure it out! If he wants me, he'll take me! If he wants me to live he'll fix my diabetes!" Now I am fuming! For better or worse I was "blessed" with a sharp tongue and quickly state to the patient, "God only helps those who help themselves." The patient continues to raise a scene and putts away in her scooter (which is now leaning to one side as she has been rocking back and forth in it). My intern looks at me with disbelief, I tell him "Some people just don't care."

This was an extreme case of ignorance on multiple ends. However, this could be avoided by one simple way. Put a pharmacist in a physician's office. I understand this has some high costs with it as most pharmacists in my area get paid right around $100,000 a year. With the cutbacks by government programs, which are the biggest payer of health care, this can really strap physicians and their practices.

Here's my justification and solution.

If it takes me 10 minutes to get a hold of someone at an office who can help me, that's $10. Include the office help time and the nurse or physician's, that number jumps to ~$25-$30. This is assuming an office person spends 10 minutes at $20-$25/hr and that the physician only gets paid double what I do and spends 5 minutes on the problem. Multiply this by the number of calls I make daily for things like this, about 10-15, that's easily $250-$450. Extrapolate that number to all of the pharmacies in the metro area in which I work in, according to Google is 2,676, that number booms to $669,00 - $1,204,200. This number represents wasted time for pharmacists, physicians and office staff. The scary part is this number is probably low since most office staff have to hunt for answers after I leave them a message. Physicians have to go and look up more info and spend more time, which is more money. This number may also be low because my pharmacy is slightly below average for volume as well.

So what could reduce this cost?

If a pharmacist was to work one day a week in a physician office and work for 5 offices, that would only cost and each office ~$20,000 a year, which is less than they pay most, if not all, of there staff. Most practices have multiple physicians so they have higher patient volumes. A pharmacist could work with the staff and physician to review charts and ensure patients are getting correct prescriptions that can be filled by pharmacies easier thus resulting in less money being spent on wasted time. This would also result in the staff and physician being better educated on what it is pharmacies need to get patients their medications easier and possibly cheaper. I have no way of measuring the statistics of how much this could save patients and thus insurance companies as well as government programs but with my experience, I am sure it could easily be millions in just the one metro area I work in. This could be another benefit and cost savings which a pharmacist could help greatly reduce. Maybe the government would be willing to pay a little bit more to physicians if they saw a decrease in the back end of prescription costs. They may argue this is what their prior authorization process is for but, honestly, that just costs physician's offices and pharmacies more time. Most patients have more time untreated and end up frustrated or not getting their medicine. This problem can from here just snowball, but could have been prevented with a pharmacist on the physician staff. With the loose math above, this means that roughly 12 pharmacists could cover 60 physician offices! If you had several head pharmacists and made a residency program out of it you could cover even more!

Maybe I am aiming to pie in the sky, but to me this make to much sense financially and medically. Why not try to save money, decrease government spending and improve medical care. Many studies out there already back these claims up, so why are we not seeing more of this? I wish I knew, but until that day I feel that it is too many times we are, figuratively, just giving the fried chicken to the diabetics and only creating a worse situation for everyone involved.