http://www.washingtontimes.com/news/2012/apr/29/fda-may-let-patients-buy-drugs-without-prescriptio/?page=all

The jist of the article (for those too lazy to read it), is that you would go to a kiosk, and via a handy flow chart be able to obtain an Rx for antibiotics (!!) hypertension medication, cholestrol medicine, etc without seeing a doctor.  Your helpful pharmacist would help you from then on out.  Yeah, as if that’s going to magically make you become more compliant.  I’ll get right on that after my job as the vicodin-police, insurance agent, and your personal fucking nanny are done.

Lets take a journal into sarcastic TAP-land:

I think this is a completely fucking great idea!  We all know that Rx medications are completely safe, require no professional monitoring, and can cause no harm to the patient.  I mean who in the fuck cares if your potassium goes through the roof when you’re on an ACE-I, or if you get rhabo while on that statin.  This whole Rx concept is obviously a cartel plot by the medical industry to milk you out of copay money to line the pockets of BMW driving doctors as they light their cigars with your crisp $100 bills gotten from your copays.  Its not like those doctors know any more than the crackhead off the street…..

Shit, this whole idea of people just making shit up at kiosks to get a truckload of antibiotics is such a good idea!  We all know that antibiotic resistance is just a big fucking lie made up by the pharmaceutical industry so they can push their ‘newer’ expensive antibiotics to leech the consumer dry.  In fact, all of medicine is a big fucking lie meant to milk you out of your hard earned cash.  See this MD/PharmD degree? Thats just made up letters that we got from a mail-order school.

Travelling back to real-life common-sense land:

This whole clusterfuck was meant to save the patient money they would have spent seeing a doctor.  Because thats SO MUCH FUCKING LESS than say a hospital admit because your potassium shot up to 12, your kidneys stopped working because you have renal issues and had to get that ACE-I, or because MRSA is eating your face off.  Not to mention the tons of other issues that come with taking A CONTROLLED FUCKING POISON that externally influences certain enzymes and receptors in your body thereby circumventing your body’s own natural regulation pathways.  Oh shit, you didn’t know that most (if not all) drugs did that? Actually I’m sure you probably thought medications were made from unicorn farts that magically made you better.

Here is a fucking great idea, why don’t you use your doctor to DIAGNOSE whats wrong with you, and have the pharmacist PICK OUT THE RIGHT MEDICATION.   I mean we all know that 90% of our time is just faxing the doctor for a drug change because its the insurance company, not your doctor who decides what drug you get.  Tell us whats wrong with you, any lab values that we might find useful, and let US pick out the most effective and affordable drug.  Pharmacists are immune to the drug-rep masturbation, we (for the most part) know our shit, and our ass is on the line with you by default if the shit goes south.  The hard cold fact is that MD’s are good at figuring out whats wrong with you, and WE are good at what drugs to use.  Same coin? Different side? Sound familiar?  Obviously not to the FDA.

If the APhA is all about this, its just more evidence that they are focused at planting new pharmacy trees while the retail pharmacist forest behind them is burning to the ground.  Why are they always ignoring what needs to be fixed in lieu of added work for no added money for us?

Oh, and if you are thinking “Well it works in Mexico”, take a second and think about what happens if you take something and die in Mexico.  Do you get to sue someone? Do you get compensation from the manufacturers? Nope, you get a dirt-nap and a “Oh thats too bad”.

But really, what the fuck do I know.  I just count by 5′s all day while watching Dr Oz and drinking coffee.

I recently had the pleasure(?) of spending some quality time with a bunch of pre-pharmacy and pharmacy school students a few weeks ago.  Since they all look up to me like I’m the Asian Jesus, I decided to be an excellent role model for them all (in typical TAP fashion, although they dont know I’m TAP)…….

I told them how retail pharmacy really is.  No candy coating, no bullshit MTM verbal masturbation sessions, no smoke-up-ass like *PhA loves to throw at them.  Just both barrels right to their faces about exactly what life is like in the trenches.  For those who didn’t cry or decide that it wasn’t worth it, I offered them gems of whiz-dumb having both gone through what they are going through now (school) and the transition into being an adult with bills, responsibilities, and a full time job.

One of these topics was how to handle pharmacy-related stress.  I swear I should teach a fucking class on this, but I doubt any school would allow some asshole who shall remain nameless and I to wheel in a pony keg and a few cases of scotch into the classroom.

For those of you at home who think being a pharmacist isn’t stressful, go into your local retail pharmacy at opening and closing on Monday and Friday.  Notice the scramble running around in the back?  Thats a pharmacist about to flip his shit.  The public thinks we just count by 5′s and drink coffee all day.  Well, I cant blame them, because thats how we’re portrayed in those shitty Target commercials:

Lets examine a few (oh boy).

**UPDATE** Someone (ahem) made these videos private.  Whoops!

Okay, so the glaring obvious errors with that commercial is that…. Its all fucking made up.  Whoever made that commercial obviously has not worked in a pharmacy, went to pharmacy school, or has waited in line in a pharmacy.  Lets show that kid fucking crying in her book hating her life as shes studying for that kinetics final.  Lets show her graduate working graveyard (because the market is hosed) with some crackhead giving her both barrels about their fucking soma being too early.  ”I am a medical dictionary” turns into “I’m a fucking narcotic dispenser”.  Oh, and who’s going to pay for “Flu shots for all”?  For all of those retail pharmacists out there, when was the last time you got to whip out a word larger than “Not Covered”, “Copay”, “Too Early”, “Doctor hasn’t faxed back yet” or “Yeah, we have the yellow Norco”?  Yeah, thats what I thought, medical dictionary my fucking ass.

**UPDATE** There was an awesome “sneeze whisperer” youtube video here, but someone got butthurt and made them all private.

I hate to break it to you all, but allergies isn’t fucking rocket science.  This commercial makes the public think that allergies are some complex thing that you need a PharmD to treat.  Take some fucking claritin/allegra/zyrtec and GTFO.  No, your insurance won’t cover that, but my foot will assist you in your travels.

A few coworkers saw this bullshit and we came up with a better version (that I’m allowed to make parts public).

“I am in Rho Chi”

“I took the State Boards 3 times”

“I have an internet girlfriend”

“Nobody knew who I was in school”

“The tampons are on isle 4 next to the maxi pads”

“I am a raging alcoholic”

“I masturbate to 2-girls-1-cup”

“I asked stupid questions in class so my classmates knew I still existed”  (You fucking know exactly what im talking about, dont you?)

You get the idea.

The fact is that unless you’re doing under 20 Rx’s a day, real life pharmacy isn’t that laid back and awesome.  The only place I have time to ponder life like that is when I’m taking a shit, and even then I’m trying to birth it out as quickly as possible because I have 3 lines on hold, a little old lady who wants to ask me the same question she asked me last week about her Aricept, a crackhead who wants a price on 460 oxycodone 5mg from an out of town doctor, and my tech decides that now would be a good time to pick up her kid from school.  Hows that for a fucking Target pharmacist commercial”

“Im too fucking busy for this shit, get that fucking camera out of my face, SOMEONE GET LINE 2!!! JUST GET A FUCKING MESSAGE HE JUST WANTS TO GIVE ME HIS RX NUMBERS! What did I say about that fucking camera!  Fine, IM A TARGET FUCKACIST, I SAY GET THE FUCK OUT”

Now that I’ve gotten some random rage out of the way.  Time for the vicodin and soma of this little rant.  How to deal with stress from pharmacy and how to tolerate your life in retail pharmacy.

1. Alcohol doesn’t solve your problems.  Ironic that I’m writing that as I swig out of the bottle some shitty wine that a patient brought in for us for doing something that I really dont remember, but somehow he thought I was the shit.  Don’t turn to booze to solve your issues.  If you do, you might get a pharmacy book published, be part of the cool kids club on twitter that has more followers than our national association, and get to use 4 letter words on the internet and people love you for it.  Honestly, in all seriousness, all joking aside, this wine really fucking sucks.  Oh well, its getting this post made isn’t it!  Oh, yeah, don’t drink to solve your problems.  Its a short term patch for 30+ years of fucking hel-OH HAI WINE!
2. Only vent to people who understand.  You went to school, you made friends (unless you’re a Target Pharmacist!).  Hell, you probably even joined an awesome pharmacy fraternity where you became a ‘leader in pharmacy’.  Those are the people who you want to vent to.  Avoid venting about work to non-pharmacy folks.  They will think you HATE your job.  Unless they work in a pharmacy, they don’t understand the stress and pressure of working in one, let alone being the person who’s license is riding on everything.  If all else fails, write out the anger, it worked for me.
3. You are just as important as the lowest paid person who you employ.  This sounds sorta funny, but if you walk around wielding your PharmD like its the holy grail and make people call you Dr, your life is going to suck.  Your techs and your clerks are your work-family.  Unless you want to be counting out everything, ringing up people yourself, and screening all your own phone-calls yourself, treat them with respect and kindness.  Trust me, being high-and-mighty will just put your nuts in the vise when the shit hits the fan.  A good time to pull out the PharmD card, is when some douchebag patient is giving your clerk both barrels over their own fuck-up. Use your authority on the patients when they get uppity, not on your staff.
4. Get a hobby that has NOTHING to do with pharmacy, medicine, the store, etc.  Collect stamps, work on cars, do SOMETHING other than come home and stew about work.  Your family, your marriage, and your sanity will love you for it.
5. Leave work at work, and home at home.  This is harder than it sounds, but being in a shitty mood when you get home everyday is just going to be the turd in the family punch bowl.  A lot of people learn this the hard way.  Don’t blow up at your family (or kick your dog) over what happened at work.  On the same token, if your kid really pissed you off, don’t bring it to work.  It’ll just distract you and thats where errors start to creep in, then you are REALLY up shit creek.
6. Make your hard work worth it to you.  This goes back to the hobbies.  I know you have student loans, car payments, house payments, but once in a while you need to buy yourself something nice to reward yourself for waking up every morning and dealing with the daily grind.  It doesn’t have to be expensive.  My favorite self-treat is lunch.  Usually taco-bell, the cheap-as-shit menu, and its always cold by the time I get to it.  Don’t fucking laugh at me.
7. Don’t self-medicate.  Seriously as shit about this one, go through the right channels to get antidepressants, anti-anxiety meds, and other Rx only shit.  You will fuck yourself over if something happens and you don’t have the paperwork to back it up.  Even if your doctor says “You know more about this shit than me, pick whatever you like”, either have the documentation in order or have a damn good story for when the shit hits the fan.  I used to jokingly say in school that “There are 2 types of pharmacists in the world, ones on antidepressants and ones who are raging alcoholics.”  You have no idea.

That’s the jist (from what I can remember) that I told these impressionable, moldable, vulnerable young people about how to survive retail pharmacy.  I’m hoping that I can single handily either save retail pharmacy, or fuck it up more than Express Scripts.

Oh, in case you were wondering, this wine still tastes like shit.

Now there is something really unique about me.  I have an uncanny supernatural ability to keep a straight face.  Doesn’t matter how loud someone blows a fart, or if I’m consulting on how far up your vagoo you need to shove that monistat 7 applicator (Uh, to the hilt baby, fish that fucker out with your fingertips!) I wont crack a smile, or laugh, or do anything but be Mr Professional.

In fact, its a rite of passage in the Angry Pharmacy for new employees that while they are helping a patient, I rip the loudest, rumblest, most wet sounding fart I can muster with the pot of coffee in me, then stand there looking over the very top of my monitor to what happens out front.  Ive learned that if you pretend you didn’t hear it, they patients don’t think you did it (or they are hearing things).  The seasoned employees quickly turn around to “check on the bags” or to do something while they laugh to themselves while the newbie sits there staring the patient in the face wondering what the fuck just happened.  I don’t care if its fucking unprofessional, coffee makes you fart and its better to let it rip than to hold it in and end up blowing ass-chowder later on during the day when you’re up to your armpits in new prescriptions.  A few times this has backfired on me and I actually shit my pants in the store, but even the best have a bad day.

Anyway.

It was winter, cold, damp, winter.  The day previous I stayed late with a few of my clerks to mop the floor out front.  I was pretty proud about how clean we got the floors.  That was karma warning me my day was about to get a whole lot worse.

There had been a bug going around town that caused a sudden urge to puke your guts out.  Some call it the stomach flu, I call it CHA-CHING the price of compazine just went up!  The store was absolutely full of idiots with Z-Pak prescriptions for their colds.  Im not sure why I decided to look up from my usual 1000 yard stare into my monitor trying to decypher a stupid insurance reject, but I remember the guy plain as day.  The glazed over look in his eyes, and the urgency that he must cut everyone off and march up to the front of the line.  He ran to the front, and waved the prescription in my clerk’s face like it was a winning lotto ticket.

“Can you please fill this for me right now, I dont fee-BLLLLLLLLLLAAAAAAAAAAAAAAAAAAAAARRRRRRRRRRRRRRRRRGGGGGGGGGGGGGG.”

For a second, time stopped as I saw pancake batter consistancy vomit erupt from the mans face, and plop down onto the counter.  The clerk jumped back like a snake was going to bite her vagina and threw me the prescription as the vomit was making a perfect large pancake pattern on top of the counter in front of him.  I scanned the room as the chatter of pharmacy died down to an eery silence.  Vomiting is contagious, and I looked with almost childlike glee to see who would start to dry heave.  To my dismay, everyone covered their faces and eyes and no chain-puking took place.  I was disappointed.

I looked at the prescription that had been clutched so tightly that it was nothing more than a ball of clumped moist paper.  Compazine tablets.  I decide to take matters into my own hands and change the tablets to suppositories, since I’m sure the floor doesn’t need any Compazine, and thats where these tablets were headed if he put them in his pancake-batter dispenser.

The poor man got a free garbage can and was on his way sitting down when another wave of heaves took their toll.  The sound I heard after that (over the heaving) I can replay it in my head 1000 times, but its hard to put into words.  The closest thing I can say is that if you percolated air through thick chocolate pudding and muffled it with a pillow.  Thats what I heard.  Oh, and I used chocolate pudding for a reason, because thats the consistancy of what now filled the poor mans pants.

At that point the entire store was in horror.  Me, being a compassionate caring pharmacist, was sorta pissed off that my ingenious suppository switch was in vain.  Tablets go in, tablets go out.  Suppository goes in, suppository gets shot out.  I seriously couldn’t win.

The poor man eventually left with suppositories in hand, and 2 free garbage bags to take with him on his journey home.  The bucket, gloves, mop, and squeegee came out to clean up the mess, and life went on as usual.

If you work retail, this will eventually happen to you.  Mark my words, your floor will be a magnet for vomit and poop.  Not just any poop, usually old people poop or little kid poop (that they like to step in afterwards and track all over the pharmacy while the mother ignores them while texting her baby-daddy).

It always happens after you stay late to mop the floor.  Every. Single. Fucking. Time.

I’m of course, talking about the MediCal 10% reimbursement cut.  For those not in the Stupidty State, MediCal is our implementation of Medicaid.

Let me back up to explain some stuff before I go on this rant so those not in pharmacy will understand.

You know when I bitch about getting paid $1.50 over my cost of the medication fee?  Thats called our dispensing fee.  Thats the amount that I make over the cost of the medication that covers my labor, the vials, the power, the tech who fills it, the clerk who has to take your annoying phone call, etc.  I’m hesitant to call it a ‘profit’, because in most cases its not.  It allows us to stay in business.

Now, back to the rant.

Usual reimbursement from MediCal is our drug cost (give or take a few percent to account for wholesaler markups, etc) plus a dispensing fee of a single digit number (less than 10 bucks for those drunk at home).  If I dispense, say, Fukitol, with a ballpark (yet entirely reasonable) price of $200, I can expect to make about $210 bucks.  Those slow out there may be saying “HOLY SHIT, YOU GOT $210 BUCKS FOR THAT PRESCRIPTION! PHARMACY IS A GOLD MINE!”  For those who think this, go work for the State of California, because you are a fucking retard.  Yes, we did get reimbursed by the state a whopping $210 dollars, but unless I can wave a magic wand and make drugs out of thin air, my wholesaler wants $200 out of that $210 so he can pay HIS bills.  So I get $10, which really is fucking good.

So California; despite having Silicon Valley, Google, dot.millionaire companies, San Francisco and LA (that combined pay more taxes in one second than we will all make in a lifetime) is broke.  Go fucking figure.  They decide to whack the MediCal reimbursement for drugs by 10% to stem the bleeding of throwing the baby out with the bath water.  This first was voted into effect on June 1st.  Us pharmacy and medicine peeps said “HOLY SHIT, YOU CANT DO THIS” and did what Americans typically do, tie it up in the courts (read on and you’ll see why).  Well, recently they lost the injunction, so the cuts happened.

Now you may be thinking “gee TAP, 10% cut in your fee isn’t so bad, thats only like a buck”.  Therein lies the problem.  MediCal didn’t cut our dispensing fee, they cut THE WHOLE FUCKING REIMBURSEMENT.

Quick and Dirty:

Drug costs 200 bucks.  We get paid 210 bucks.  Take 10% off of that 210 bucks and you’re left with 190 bucks.  The drug still fucking costs the pharmacy 200 bucks.  We make a whopping -10 dollars.  Thats right, the pharmacy LOSES 10 dollars (in this case) with EACH FUCKING HIGH DOLLAR TRADE NAME FILL.  Throw in some chemo drugs like Xeloda that costs the pharmacy THOUSANDS or HIV drugs at 600 bucks each, and you have yourself a closed pharmacy.

But no, it gets better.  You see, MediCal is in bed with the drug manufacturers.  The drug manufacturers give “kickbacks…er..REBATES” to the state to use THEIR  product.  Why else do you think Nasonex is the ONLY nasal steroid instead of generic Flonase.  Why do you think generic Morphine ER isn’t covered, but BRAND ONLY Kadian is?  The state is getting a rebate for having these on their formulary.

So not only do we lose money on each brand-name prescription, but we are forced to use brand name for certain drug classes.

See how absolutely fucked this is?  So whats a pharmacy to do?

Easy, send the patient somewhere else for brand name drugs.  California Business and Profession code prevents the selling of products for less than what it costs you.  Its part of the anti-predatory pricing laws.

Does this suck for the MediCal patients who need HIV/Actos/Nexium/Kadian/etc? Yup, it sure does.  Our hearts are out to those patients who can’t get their drugs filled, but what other choice do we have?  The chains can absorb the cost for a time until they pull the plug, and the independents cant absorb any of that.

Oh no, it doesn’t stop there.  You know how I said that the cuts were put into law June 1st but got held up in court?  Well they made the cuts retroactive.  Pharmacies are going to get a BILL from MediCal for the 10% difference for EVERY FUCKING PRESCRIPTION they filled since June 1st.

If you are an independent store owner, give money to the Pharmacy Defense Fund (if you haven’t already).  If you’re a district manager for the chains, get your head out of your ass and tell your people to STOP FILLING BRAND NAME DRUGS or you might be out of a job.

I’ll leave you with that.  Don’t send me the bill to cleanup the mess of your head exploding.

I’m talking about people who work with the public.  Hair dressers, Pharmacists, Doctors, cashiers. The kid who bags your groceries to the checkout line clerk to the nice lady who takes your order at the fast food joint.  You know who they are, they greet you with a smile and a silent anxious look in their eyes that you won’t rip their head off over something that is completely out of their control.

What sparked this?  A visit to the supermarket.  They were having problems with their ATM/Credit Card thingy.  The cashier said outright “Im sorry, but we’re having system problems processing ATM/Credit/EBT cards, it make take a try or two for it to go through”.  The ungrateful waste of skin proceeded to give her both barrels about how this was unacceptable, that they should have their system fixed, they should have a system in place to fix this, should have, should have, should have (notice I didn’t say ‘should of”? Be proud Mr Woo).

I was the next in line, and by the time this douchecanoe actually got his 6 pack of natural-ice with a carton of cigs ran through the one out of 3 credit cards that were not maxed out (after getting pissed that their food-stamp card can’t be used for that/it was tapped out), the poor checkout clerk nerves had been totally fried.  It only takes one asshole to ruin your day.  I gave her a smile as she rambled through the warning that the checkout computers were going in and out, blah blah blah, to which I said that there was no problem.  I realized the look in her eyes was the same look that I probably have when I miss filling a prescription that was buried in a profile and expect both barrels from the patient when they have to drive back to the store because I overlooked something.  I was kind and patient, and she gave me a sincere thank you.  I told her that I work with the public too and its like she knew that I understood her pain.

I’ll be upfront.  I have never sent back food anywhere because it wasn’t up to my standards.  Even if its the absolutely wrong thing I just eat it.  I tip the person who cuts my hair the same even if its a horrible job or the best job they ever did.  Someone fucks up putting the price in wrong at the grocery store and I don’t get that $0.50 discount I don’t say a word.  People say that I just reinforce the mediocre half-ass-is-okay work-skill that plagues our working class.  I say that I don’t want to be ‘that guy’ that makes people drink as heavily as retail pharmacists do.

You ever stop and realize that the assholes of the public will gladly wait in line for 15 mins for a seat at a restaurant, but can’t be bothered to wait 15 mins for their 5 (free) prescriptions?  Interesting isn’t it.

During the supermarket incident, I realized that all of us who work with the public are in the same boat.  We deal with the same assholes, the same impatient fucks, the same douches who bitch that their prescription isn’t ready yet when the power is obviously out and I’m trying to keep the pharmacy systems up while a generator is obviously screaming behind the store.  I can always tell when a patient of mine works with the public.  They are pretty nice, easy going, and realize that sometimes shit happens.  They patiently wait for their prescription, and use the foreign words we never hear like “please” and “thank you”.  They are mindful of our time and actually show appreciation to the service that we give them.  How foreign is that in a pharmacy?

Its ironic that the most important aspect of retail pharmacy isn’t all the drug-drug interactions, the kinetics (learned for the test, then quickly forgotten; never to be used again), knowing the pharmacology of benzodiazepines, or even the rationale behind giving someone an ACE-I in CHF; its dealing with the unwashed masses.  The most important aspect (and the #1 cause of burnout) that is just blatantly ignored in pharmacy school.  ”You’ll just learn it on the job” they say as your day is shattered by someone yelling at you who have never worked a day in their life.  Thats like teaching you how to swim by throwing you into the deep end and yelling “You learn by doing” as you slowly sink to the bottom.

Pharmacy school should have a class that is like a boot camp, you get yelled at each class so you’re used to dealing with idiots who give you both barrels over the most stupid things. You learn how to defuse situations.  Ah shit, who am I kidding.  Pharmacy schools would probably teach you to use fruity ‘touchy phrases’ like:  ”You know by saying that, you hurt my feelings and make me feel less about myself” to which the patient would reply “Good, you’re fucking stupid, my vicodin is due now, not next week”.  Color me surprised that pharmacy schools are so out of touch with the ‘real world’ that they wouldn’t know their poop-chute from a hole in the ground.

I realize that this post isn’t your usual swear word ridden bitchfest, but fear not, I take care of my readers (sorta).  If you want to re-post this article, this would be a good time to stop copy/pasting.

So to all of you ungrateful fucking assholes out there who decide to ruin the day of us who get our asses up every fucking morning so we can serve you, heres a fucking tip from the guy who double-counts your fucking dope so you don’t come back and say that I shorted you.  Get a fucking job, work with the fucking public, see what its like to deal with your own fucking kind.  Get your day shot to shit because you had to serve a fucking asshole like yourself with the social skills of a fucking steaming turd baking in the afternoon sun.  Get a dose of your own fucking medicine.  The world owes you shit.  Be thankful you live in a fucking world that we accept you for the shit you do to us day in and day out and don’t take you out back and shove our boots in your fucking yappy twatty mouths.  If you think you can take your bad day out on us, feel fucking free; but beware, theres nothing I can really do to you in pharmacy, but I’m sure the server would be more than happy to let your fucking food you sent back 3 times because your steak “wasn’t cooked enough” fall on the floor a few fucking times when you’re not looking.

I hope I filled your use of the fucking word ‘fucking’ per post requirement.

I’m talking about the dreaded ’0 refills remaining’ with the patient being out for 2 days.  This phenomenon is so prevalent in pharmacy that we should have received a class on how to handle it.  Since pharmacy schools give two-shits about retail, here is your class on the subject.  Pay attention!

This is how 99% of the cases take place:

• The patient will call you over every little change on the label (expiration date, change in manufacturer, quantity, doctor) yet will gloss over how many refills remaining until they are out for exactly 2 days.
• The patient will let you know they are out of refills in person…. On a Friday… Before a 4 day holiday…. At 2 min’s to closing…
• The mediation won’t be Vicodin, Valium or any narcs.  It’ll be something awesome like insulin.  You know, the kind of shit that you ethically can’t tell them to go fuck themselves over.
• They won’t be out of something simple that you can drop a few tablets in their bottle, it’ll be something that comes in a unit-of-use bottle, like Januvia, Actos or Nexium.
• In the event that they are out of something simple and stupid, they will forget their old bottle despite you telling them 10 times “MAKE SURE YOU BRING YOUR OLD FUCKING BOTTLE”.  This leaves you out the cost of ANOTHER bottle and ANOTHER label.  Regardless of how shady this all is already, dispensing drugs into their open unwashed hands is just crossing the line.
• The patient will use the phrase “BUT I NEED THIS MEDICATION” or “CANT YOU JUST FILL IT”.

Here is where the legal waters get the product of Go-Lytely dumped into it.  What do you do?

• Legally (sorta), you can only give a 3 day supply without authorization.  Its insulin.  Are you going to suck out a 3 day supply?  If you are, I hope your employer fires you for being a dumbshit.  Are you going to break open that box of Humalog Flexpens to dispense just 1?  To make this worse, if the MD finds out (usually patient taddling) he/she could file a complaint against your license with the state board of pharmacy for filling without authorization.  If you billed the insurance company, they can ding you for filling a fraudulent Rx and pull your contract.  This is all worse case mind you.
• Realistically, you know you won’t get the OK from the MD for at least 5 or 6 days.  A week to 10 days if the patient goes to a county-ran clinic at the local hospital.
• Ethically, you know that if you don’t dispense this insulin, the patient will have to go to the ER (or worse) thereby costing the taxpaying citizens a few thousand.

Pretty fucked situation all around?  Yes, yes it is.  For those of you at home, we deal with shit like this about 20 times a day.  Now this is how I would handle it:

If it’s a regular patient (regular in the term that we have a professional relationship, not that they can poop fine), then I take the potential legal hit to my license (and to the store) and give them the insulin without the authorization.  I figure the patient will stand with me against the state board (and their doctor) to justify my actions as being in their best interest.  I politely tell them to bring me a new Rx before this amount runs out, and all is happy.  Wait, can you hear the collective jaws of every MD out there dropping as I spill the beans that yes, we do dispense medication without your authorization in certain cases.  Here’s a fucking reality check, your patients are dipshits.  They can program their phones to play the most obnoxious ghetto rap-song ring-tone at 1000db while waiting for their drugs, yet they can’t program a simple alarm to remind them to call in their refills a week early so we can get the authorization.  If you are unable to grasp this concept, then actually listen to the ‘blah blah blah’ that comes out of their mouth when they visit you and you’ll realize that you’re dealing with someone that’s half-step above my dog on the evolutionary chain.

If its Joe-Crackhead who treats me like utter shit, bitches at me about EVERY-FUCKING-THING and looks for things to argue about; fuck him.  Let him sit in the ER for 10 hours.  If he paid as much attention to his medication refills as he does his fucking cigarettes, we wouldn’t be in this mess.

Harsh? Yes.

Surprised? No.

Agree with me? Probably.  Here is my rationale.

Personal responsibility is something isn’t to be taught by your Pharmacist.  Sure, everyone has a brain-fart and forgets to call their medications in.  However why should I legally put MY license on the line for someone who has no respect for me, doesn’t treat me like an equal, or always tries to pick a fight for me?  This kind of bullshit patient would be the first one to throw me under the bus to not only the MD but the state board if the shit goes south.  I’m not going to put my livelihood on the line for someone who doesn’t give me an ounce of respect, and doesn’t realize that I’m doing him/her a huge favor.  Unprofessional? Sure, if you want to look at it that way, but you also need to look at the irresponsibility of the patient who put him/herself in that situation and expect me to put my ass on the line to remedy a situation that he/she put themselves in.

The easy solution is for everyone to have a little bit of self-awareness and personal responsibility regarding their own health.  Yeah, I’ll get right on that after I finish filtering all the piss out of the ocean.

Several factors led Morton’s executives to make the decision to sell most of its retail pharmacy business. “It’s the declining reimbursement environment, mandatory mail-order plans, the closed networks that are starting to become popular across the country, $4 generics programs, and predatory audits,” Morton said.

Both health insurance companies and government programs are slashing reimbursements, according to Morton, a practice that is “not providing enough margins for us to serve patients.” In addition, the purpose of audits conducted by pharmacy benefit managers (PBMs) has changed from detection of fraudulent claims to making extra money for the PBMs, according to Morton. “They are looking for administrative mistakes so they can look to recoup claims. It is a revenue-generating technique,” Morton said.

For those not in the industry, Walgreens has a Pharmacy Benefit Manager called Walgreens Health Initiative.  This is similar to how CVS/Caremark work, and the infamous Merck/Medco.  Now for those of you who work retail, this whole article makes perfect sense.

1. Have your PBM give ridiculous low reimbursement rates to kill the independents.
2. Be first in line to “take your failing pharmacy off of your hands for you”
3. If they refuse, audit the shit out of them for every little fucking thing until you bankrupt them
4. See step 2
5. Profit!

Funny, how it’s technically illegal for a bunch of independents to meet to discuss if they are going to take a PBM contract due to antitrust laws, but the major chains and their PBM backers can pull this kind of bullshit.  Of course the major chains can bribe (yes, I said bribe…er.. LOBBY) the corrupt government to look the other way.

Having gone through a dozen+ audits, the article is 100% right.  The auditors aren’t looking for blatant fraud and abuse, they are looking to generate profits.  When you fill an Rx, if you mark a faxed back OK as ‘written’ in your software (instead of a ‘faxed’), that’s grounds for them to take the entire cost of the Rx out of your next check.  I bet, with a bit of digging, you’ll find that these auditors actually get an incentive-pay based upon how many ‘errors’ they find on the pharmacy end.  I will also bet that Caremark doesn’t audit CVS stores, WHI doesn’t audit Walgreens, and Merck doesn’t audit the Medco mail-order chains.  Even if they did audit them, do you really think they would take the money out of their next check? Isn’t that taking money away from themselves?

Sometimes the audits pick up things that are just mistakes, like when you have a Robatussin-DM in your computer as 1 bottle of 273mL and your floater bills 273 bottles by mistake thinking that it’s in the computer as per-cc instead of per-bottle.  Those I can see, but taking back the ENTIRE reimbursement over a 28 day supply vs 30 day supply for eye drops is petty and bullshit.  We have the Rx, its legit, yet you are back-charging us for the entire amount due to a clerical error (and a stupid one at that).  The Rx wasn’t filled fraudulently, and it was filled in good faith with no intent to fraud.  However try to argue this point with the auditors and you’ll just get a blank stare and 100 more ‘errors’ that will make your next reimbursement turn into a bill.

So the million dollar question is: Where is APhA in this mess?

Its the dreaded RTS bin.

Thats right! The Return To Stock bin.  The glorious bin of drugs that patients called in to have refilled “RIGHT NOW” yet never got off their lazy asses to come and pick up.  You know, all the simvastatin and lisinopril that the patient pitched an absolute fit right in the store because they “were out” and didn’t have any refills remaining yet never bothered to pick up 2 weeks later.

RTS’s absolutely kill pharmacies.  Here’s why (to those at home who don’t work in a pharmacy).

It takes money to fill a prescription (gasp!) other than the raw cost of the drug.  Everything from the vial, to the label, to the computer system/printer/toner that spits out the label (that you fucking don’t read) to the tech that fills it, to the pharmacist that checks it, to the clerk that puts it in a little bag and takes your whiny phone calls.  All of those steps cost money.  Thats not even counting the electricity, insurance, employee taxes, etc.

We get a dispensing fee paid for by YOUR insurance to cover these fixed costs.  Why are they fixed? Because the dispensing cost is the same if the drug costs $1 to $5000 kerzillion dollars.  When you pick up and sign for the medication, we have proof to your insurance company that you in fact received the medication and their piddly $2 dispensing fee was in fact put to its intended use.

Now say that drug filled vial with your name on it just sits out front for a few weeks.  It starts to get lonely sitting by itself in the pharmacy because contrary to what you read on the internet, just ordering your medication doesn’t make it magically work, you need to TAKE the fucking medication.  Eventually, we need that space to store medications for people who give a fuck about their health.  Your vial then gets RTS’d.  Since we didn’t dispense that medication, we legally cannot accept the money that your insurance company paid us for the drug + dispensing fee.  So now, we “back out” the prescription (meaning we give the money your insurance company paid us BACK to them, all of it), and now must PAY someone to put the drug back into the big stock bottles.  We have to throw away the vial and the label as well.

Your laziness now has cost the pharmacy double the labor + the cost of the vial/label  for which we are getting paid a whopping $0.00 for.  All because you called in a refill and didn’t get off your ass to pick it up.  My store has a policy that we call people once their medications have sat for a week, then we give them a second call 5 days later.  Yes, we PAY someone to call you to remind you that the prescriptions that YOU CALLED IN have sat here for a week.  This is after we told you when you called in your refills that they will be ready later on that day.   Ask me how this can be any more straightforward!  Oh, I guess its as straightforward as paying your fucking phone bill because every time you come in you give us ANOTHER phone number (thats disconnected 2 days later).

After about the second time I RTS a prescription for a patient, I put a big note in their profile to make sure they are told that we will fill their prescriptions when they are IN the store due to us always putting back into stock what they order.  What do I get? A bunch of swearing at me from over the counter by some idiot unwashed mouth-breather to the tune of “I called these in a week ago, why aren’t they ready yet!”  This is after they were EXPLAINED why they must be here for me to fill their “diabeetus and list-o-pril” pills.  I swear I can’t fucking win.

This shit really pisses me off.  Its a waste of my fucking time and a waste of the stores money.  Since my store doesn’t do auto-fills, if you’re not going to take your fucking medication, then save us all the headache and don’t call it in.

Oh, and a cool pharmacy fun-fact, is that controlled prescriptions are a good chunk of what I fill everyday, yet less than 1% of the drugs I RTS.  Big fucking surprise.

It was your usual day at the Angry Pharmacy.

I got a call from a resident that I’m on fairly good terms with.  She wanted to increase the dose on a patient diabetes meds.  She wondered why the patients A1C was climbing lab after lab and thought the medication wasn’t working.

I pulled the patients profile up.

Month supply filled Jan and March.  Something wasn’t right here.  Maybe he/she was going to another store? Only one way to be sure.

I told the resident to ask the patient to bring in all of his/her meds in so I could “take a look at them”, which in pharmacy speak means “See if you are fucking taking them”.

Patient comes in with a plastic bag full of pill bottles (oh dont we just fucking LOVE it when they do that) and a new Rx.

Every single bottle of maintenance med was full.  EVERY FUCKING ONE OF THEM.  It had more fucking diabetes medication than I did on my shelf in that one plastic bag.  Most were from us, some were from a different pharmacy dating back almost a year, all were filled exactly on time.  This looked like two big scoops of not-fucking-good.  In fact, the refilling gaps in MY system were accounted for by another store’s filling.  This required a “come to Jesus meeting” by yours truly.

I asked the patient, who had almost every risk factor for diabetes in the book, why it wasn’t taking the medications.  Then the bomb was dropped.

“I know my body, and I know what its doing, I dont need this shit.  I just need my pain pills”.  Hear that needle being pulled off of the record of medicine?

Now its A1C would score a solid gold in the A1C Olympics.  I could use his/her urine to compound in place of simple syrup.  If it wasn’t the copious amounts of bullshit flowing through its veins I’m sure they would of died by now.  I asked the pushy patient if the doctor knows its not taking its medication.

“No, if I told her that, she wouldn’t give me my pain pills”.

I wanted to punch him/her in the face.  I asked if he/she had side effects, or any reason why he/she didn’t want to take the medications.  Sometimes the twice a day is too much for people, there are options that I could suggest.  This resident was an awesome one who loved pharmacists thanks to yours truly (you’re welcome) and would do whatever I suggested.  Look at me! Being all pharmacist like!

“I told you, I know my body, I dont need these, I’m fine.”  I fucking love it when they use that line.

Nothing I could say could make his/her take them.  Threats of blown out kidneys, to losing his/her sight, to not having legs, nada.  So.. Fucking.. Frustrating…  I tried to play the pain card, saying that her pain could be because of damage to nerves.  “Gabapentin doesn’t fucking work on me, neither does Vico-dan.  I need Percocet”.  This was said with a straight face as I could line the entire pharmacy an inch deep in unused gabapentin caps.  I offered to work with the patient and the doctor to help her.  I even offered to fucking blister pack the medication to improve comp-LIE-ance.  Nothing would work.  The patient had either given up, had a fucking stroke and got incredibly dumb or just really wanted to get high.  Maybe if I printed “HAVE YOU TAKEN YOUR MEDICATION TODAY” on a package of cigs or a lotto ticket it would make a difference.

The conversation turned into the “I dont want to talk with you anymore.  How long until my Percs are done” song and dance when I called it on bullshitting the doctor to get more narcotics.  Sometimes it takes being an asshole to get the point made.  My preceptor used to tell me, “TAP, never argue with an idiot, they will drag you down to their level and beat you with experience”.  If I followed that advice, I wouldn’t have any patients.  I knew that short of a diabetic complication 2×4 across its face, there was nothing I could do.

Then the blood started to boil.

This person gets FREE care and FREE medications.  It isn’t out anything but his/her own time to take care of her condition that could leave her legless, blind, and on dialysis.  Of course all care related to stupidity would be happily covered by the state.  None of that mattered to him/her.  90% of the working population would KILL to have what he/she is getting for no cost.

You know when I ranted before about how a person places no value on something that they aren’t paying for? Case in point, right in fucking front of me.

Now this person is spending, nay wasting, hundreds of taxpayer dollars a month that could be used towards someone who actually gives a shit about their health, about their care, about their body.  A person who could actually get a better quality of life while they get their life back on track.  If this douchebag wanted to just get fucking high and watch his/her health spiral down the shitter, thats great – just don’t take the resources that could be used to help someone who gives a shit.

So the question remains: at what point do we, the healthcare people, decide to cut-bait on a patient that obviously doesn’t give a shit about his/her health and is only seeing you because they are being forced to (or to get narcotics)?

Oh, and I paged the resident (I REALLY hate paging doctors, but I figured this was important) and let her know what was going on.  After a bunch of “are you fucking kidding me” she requested the patient go back to her for “clarification” on the percocet prescription.  I think someone is going to get a type-1 ass-chewing, but something makes me think its not going to make much of a difference.

I love making shit up *ahem* to prove a point.

If you’re looking for profanity, slurs against the downtrodden, just skip over this whole post.  This is a post to generate discussion about a real issue that us retail Pharmacists have with our MD counterparts.  Yes yes, I know that the past few posts I have been quite uppity and boring about some issues going around, but fear not, the poop-talk is coming.

What I shall grace before you is from my own experiences only.  Although I represent a voice of pharmacy, I cannot speak for every pharmacist (although I do damn near get all of them to agree with me).  I want the MD’s in the audience to think about this article, because its not meant to inflict harm, just bring to light exactly how us in retail feel we are perceived by you.

• Whenever we call for a clarification, you are “in the room with a patient”.  We are unable to speak with you directly.  Even if its about issues that can get you in serious trouble, like forgeries/stolen pads or narcotic shoppers.  We speak with your “nurse” who gives the message to you.  While we are waiting for your “Nurse” we have a line out the door and the hospital on the other line calling in discharge medications, yet we patiently wait.  Your “Nurse” then gives us a response which is totally different than the original question, obviously there was a miscommunication between us and your translator which wastes both of our time.  We feel that your time is worth FAR FAR greater than ours since you can’t spare 30 seconds to have a conversation with us even though we are treating the same patient.  We feel like our concerns about OUR patients (which if we are calling you, its a concern, we dont have time to just piss away) take a backseat to everything else in your office.
• On your answering machine or answering service, you give a option for doctors or hospitals to get an express route to you.  Yet you do not give pharmacists an option.  Since we respect you (and aren’t a hospital or doctor), we are thrown into the call pool with your patients to be answered by a staff, who transfers to another staff, to transfers us to your nurses voicemail box, all while your patient is feeling ill and just wants to get the antibiotics (thats not covered) and go home.  All of our IVR systems give you an express hotline to us, yet the courtesy is not returned.
• When we see you at the CE dinners, we introduce ourselves only to be shunned by you chatting with your MD friends.  When you do actually talk to us, you don’t ask us how we’re doing; you ask us to pass the wine, or to fetch you something.  We introduce you to our fellow pharmacists, yet you dont even extent the common courtesy to introduce us to the other doctors.  We treat the same patients, we are on the same team.
• When is the last time you spoke with a pharmacist that you do a lot of business with.  Not just call in prescriptions or yell, but actually ask how they are doing.  Have you ever offered to have a cocktail after work with them? We would gladly treat you to cocktails after work, yet we never get the chance to speak with you to extend the offer.  Do you even know what their name is? I guarantee that your local pharmacist knows what your first name is, shouldn’t you respect him/her and do the same?  You do treat the same patients.
• Pharmacists, on the other hand, talk to each other.  We ask how we are doing when giving transfers.  We go out for cocktails after work.  We warn each other about forgeries.  Even ones who are in direct competition have a fraternal-like bond regarding reimbursement rates and looking out for each other.
• Pharmacists have a closer relationship with your front end staff than we do the MD that employs them.  We know your nurses, they know us.  We laugh and crack snide jokes about our patients who want yet another refill for that prometh w/ codeine.

Notice a trend here?  Retail pharmacists get scooted to the side by MD’s in all aspects of our job.  Now compare this with the angry doctors on twitter, who openly joke, converse, and treat pharmacists there as equals.  Do you see why they have such a huge following? Do you see WHY pharmacist jumped to the defense of a faceless, nameless anesthesiologist who was bullied by an MD who seems like he fits the above description?  The doctors on twitter are the doctors that pharmacist love.  They don’t put us on hold or communicate to us via a 3rd party, they speak directly to us.  They are approachable and friendly.  I can send one a message and not wonder if they will ever get back to me because they will.  I don’t need to watch what I say around them for fear of getting the “oh he’s just a pharmacist” eye-roll and subsequent ignoring.  They are people, real people, like us.  If you, the stereotypical MD, treat a fellow professional like us this way, how are you treating your patients?

I regularly go drinking with a NP and an MD friend of mine from a hospital nearby, and we discussed this whole issue about retail pharmacy and the local docs.  They, working in solely a hospital setting, had no idea that this huge gap between us existed.  They thought that all the docs in the area called up their local pharmacist and ask questions as basic as whats covered, to a suggestion for suitable beta-blocker for a patient with a low CrCl.  They wondered how you can practice medicine safely without asking advice from someone who is knowledgeable about medication.

I find it interesting, that pharmacists; most if not all have doctorates, who went to school, studied, and work with drugs for a living, are ignored in general by your average MD (except when the patient bitches the “pharmacy wouldn’t fill what you wrote”, only to be yelled at by the MD because the drug wasn’t covered and costs $400).  We are on the opposite side of the same coin, and ultimately the person who suffers the most is the person who is generating the revenue so we both can eat.

Part of this is the fault of pharmacists in general.  Most of us really don’t have the time/balls to stand up for ourselves when push comes to shove regarding MD’s and medication therapies.  We have allowed ourselves to be walked upon for decades.  Ask a pharmacist who graduated in the 70′s what doctors were like back then (shout the orders, slam down the phone, “just fill the fucking prescription”).  However the tides are turning.  Residents are being taught to ask us for advice.  There are too many drugs and conditions now for one profession to master every small aspect of both fields.

I’m really not bitching per-se, just letting you all know what your image is like on the other side of the fence.  Do I expect this to magically change with one blog post? No.  Behavior that has been refined over the past 100 years can’t change overnight.  I hope this brings some insight on why the docs on twitter have such a strong pharmacy following.