medicines on table

Been a little bit since I’ve had a pharmacy rant, but it’s time for some more education. Over the last few months I’ve seen, heard, and had to deal with some extremely frustrating issues that frankly should never happen. I personally view myself as wholly responsible for my own health and wellbeing; I do not expect any other person or entity to take charge of making sure that my health is on the right track.

It’s always a sad thing when a family-owned business closes the doors, it’s even worse when it’s a pharmacy. The greatest travesty of all: the customers are part (but not all) of the problem. Corporate greed and government regulations are the other part of the problem. That being said, by remaining informed and by actually participating in their own healthcare, the patient can eliminate 90% of the problems encountered at the pharmacy.

clear plastic container and medicine capsule

What’s the problem??

Like seriously, what is the problem with people that one of those crazy coupon ladies can literally crawl up and down a cashier because one of the 236 items in her cart is missing a 50¢ discount, but when she is at my counter she can’t tell me the name of one single medication she takes?

Or, as another example, the individuals that wait until the day after we call to tell them the medication they asked us to fill two weeks ago is going to be put up today. Then they get pissed that they have to wait for their medication again. Well, duh. You got 15,000 phone calls talling you it was ready and it would be put back Monday. You showed up Tuesday.

Seriously, though, ignorance of personal healthcare is a significant issue that leads to pharmacist phrustration. You have a detailed list of every veggie you need from the grocery store, but you have no clue what those little pills are that might kill you. Let’s look at the non-patient side of things first, though, to bring some context to why our jobs can be so exasperating.

Can you fill my round white pill? No, I don’t know what it is, or for, but its round and white.

Like literally 10,000 patients out there, right now

Problem 1: The goofy pharmacy model

Common complaint I get: the pharmacy calls me too much. I agree. We aggravate the hell out of you. We’re caring healthcare workers; so much so that if I could I’d take one of those sheep de-wormer applicators and literally shove pills down your throat if it meant you actually took them. Don’t know what I’m talking about? It’s a six-inch dosing tube that we use to deposit drugs way at the back of the mouth so they can’t spit it back out. The sheep will usually be in a headlock. It’s not really fun for us or the sheep, but it does guarantee medication delivery.

In most businesses, the product is purchased by the customer and the business immediately gets paid the price of the item. Pretty typical, you pay for the product at the asking price, you get the product. Pharmacy payment pathways are a bowl of spaghetti. Literally. Everybody including the coupon lady wants their hands in the pharmacy payment pie. But nobody really wants to pay the pharmacy. Third parties are Satan, as far as we’re concerned. Yeah, we hate your insurance. Granted, they pay us, but if we could we’d take your insurance company to the train station. Bringin’ some John Dutton in here.

Payment Spaghetti and DIR Fees


$5+$5=$7?

accounting
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Direct and Indirect Renumeration (DIR) fees are the reason your phone melts through the table at the end of the year. We really want you to fill and pick up your medication.

For example, you go into Walmart and a product costs $10. You pay $10 to Walmart, who immediately sees a profit for the product you just purchased. They pay the supplier, and pocket the rest. Typically, they’re looking at a markup around 130%, so all in all they’ve came out on top.

Flip this around to the pharmacy world. Unless you are a cash-paying customer, we have to deal with Satan. Your insurance company. At my counter, you pay me your $5 copay for a prescription. This particular product costs me $5 directly. Your insurance has agreed to reimburse me $5, for a total of $10. So we make a $5 profit, right? Nope. They pay us $1 right now.

So the Walmart coupon lady pays her $5 copay today for her blood pressure medicine. Today is January 1st. She goes on her merry way, ripping up cashiers just as fast as she rips out coupons. Shes more worried about those coupons than she is her blood pressure, so she only takes her BP meds 3 or 4 days of the week. So a year later, she has taken her meds 208 days out of 365, or 57% of the year.

Now, healthcare is driven by outcomes. Or at least it is supposed to be. Because coupon lady missed taking her meds almost half of the time, she is considered non-adherent. Generally, you are adherent if you take your meds 80% or more of the time. If it’s less than that, most likely you’re spending money on a medicine that’s really doing nothing for you. It only works if you take it.

So Satan does his accounting and sees that coupon lady isn’t adherent. Of course, it’s not her fault she doesn’t take the medication, it must be the pharmacy’s fault. So, of the remaining $4 owed to the pharmacy, the insurance only pays an additional $1.

Another explanation can be found at Pharmacy Times. The point is, could you survive if you were given half what you expected, with no guarantee that the other half would ever be paid?

DIR fees are no fun. For anyone involved. DIR fees are a leading reason why prices are high at the pharmacy, and they are also a key reason for so-called pharmacy deserts. Because many independent pharmacies cannot afford to wait six months or more for payment that may never come or may actually have to pay money back to the plan (a “clawback”), often the only choice is to close or sell to a larger chain.

Factor in that on average the overhead to even look at a prescription is about $13 per script, before we even put pills in the bottle, the end result is that on many scripts pharmacies take a potential loss. Name me a business that essentially tapes money to the product as it exits the building.

The outcomes model

Part of the so-called solution to combating increasing obesity, heart disease, diabetes, and other chronic conditions was to introduce a pay-for-performance model. In theory this sounds great; healthcare businesses only get paid if they produce healthy results. The problem is this does not factor in two issues: ingrained patient behavior (more on that in a minute) and Satan. Actually, Satan had a hand in proposing the PFP model, so I guess the insurance issue is factored in, but just negated.

We, as pharmacies, are relegated to being the fast-food industry of healthcare. Healthcare, in general, has turned into a volume business in large part due to the insurance companies and government influence. We receive less and less payment per interaction, thus, to fill the gap we simply increase the interactions. Only it really is not that simple. Sure, to you slapping a label on a Z-pak should take 5 seconds or less. Unfortunately, that Z-pak comes in the middle of probably 20+ other prescriptions, 10 phone calls, 3 flu shots, 4 COVID shots, 10 patients in the store asking questions, the boss calling to ask have we had our employee engagement meeting, the tech on lunch coming back to tell me somebody in the parking lot got hit in the head by his own hammer, and somebody waiting in the store that is apparently wearing an adult diaper has filled that diaper and it is overflowing throughout the store. Oh, and by the way that Z-pak can cause irregular heart rhythm, and you probably really don’t want to be taking that with your Multaq. But yeah, I’ll just grab the box and slap the label on it, much easier to move on to the rest of the 3000 problems currently happening. Have your wife call the hospital to have a bed ready.

Now, let’s throw in PFP. All of the above, plus we’ve got to make sure our patients are actually taking their medications. In come DIR fees. I have to agree, as an insurance company why would I continue to pay for prescriptions that are not actually benefitting the patient. That being said, the target is wrong. Don’t draw the target on the doctor or the pharmacy, draw the target on the responsible party.

Convenience is a killer


close up view of neon drivethru sign
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Anybody remember the days of the soda fountain in the pharmacy? I’ve only heard of those days. I’ve heard of typewriter days, soda fountain days, the “opium” days. Seriously, go find a local mom and pop pharmacy that has been there for at least 30-40 years. You would be seriously surprised at what you may find in some of the old remedies they may still have stored away. The local druggist knew everyone in town, nobody was in a hurry, and pharmacists were the first choice in a patient’s mind for non-emergent healthcare.

That being said…today is too fast. We’re a business, so convenience is a must. We’re also healthcare, so thoroughness and attention to detail is also required. How do we blend both worlds?

Truthfully, I loathe the drive-thru in a pharmacy. In my book, that was the beginning of the end for pharmacists as professionals. You want fries or onion rings with that hydro-chlor-whatever? How about some real southern sweet tea with that meto-morfamin?

Insurance companies have not helped; shrinking reimbursement with the introduction of DIR fees have meant that to survive, greater volume must be achieved while reducing overhead costs. Bye-bye technician of 20+ years.

Now, we move to the moto of any business: if we don’t do it, the guy down the road will. Add corporate pharmacy and metrics and we do live in our own self-created nightmare. We don’t get to leave for lunch, bathroom breaks often get sacrificed for having too much to do or that patient that just can’t wait and asking for time off resembles the Hunger Games series. Seriously, I hope the odds are ever in your favor around October, when vacation bids are due.

How do we get back to soda fountain days, but still maintain the convenience of a business while also providing the healthcare service the community needs?

It’s a vicious cycle

Seriously. Pharmacies get punished for the end user not following through on a commitment. Rephrase: patient A has a heart attack. Patient A has cost the insurance company $100K in hospital bills and now is on lifelong medication to prevent another heart attack. We know this medication will reduce the likelihood of another heart attack occurring, so it makes sense that we want this patient to take a cheap, 5¢ per day medication rather than end up dead or in the hospital again. That being said, short of forcing the medication down a patient’s throat, we don’t actually control patient behaviors but we are held responsible for said bad behaviors.

Let’s look at it another way. If you are in a car accident, your personal car insurance policy premium increases. The way pharmacy works, it would be like telling the auto dealer that because people were having more accidents, they were going to get paid less per car rather than pass the punishment on to the responsible party: the consumer.

Problem 2: The Patient

Now let’s have some fun. Practical fun, but real issues we see in the pharmacy every day. My techs recently joked about what would happen if we could say what we really feel about our patients. It would be bad. Very bad. There is a point, but these serve to illustrate issues we have to deal with every day.

Bob the Builder


man carrying gray pipe
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Old Bob the Builder is a character. You see, Bob works long hours at his own contractor business. Part of Bob’s charm is his ability to relate to everybody. It’s how he secures all those contracts. He’s so awesome, he even decided to make sure his employees had company-sponsored insurance this year.

But Bob has a secret. A dark secret. You see, Bob has no spine. Bob’s wife has plenty of backbone for them both though. And while Bob make’s sure everybody has healthcare, it sucks. Like $5,000 per person deductible sucks.

Because Bob is always busy with the business, we only see his wife. We cringe if we have bad news. Here she comes.

Uber Tech: “Hi there Mrs. Bob, how can we help you today?”

Bob’s Calm Wife: “Hello there, Bob the Builder has his sugar meds today.”

Uber Tech: “Sure thing; your total today is $346.99, or your firstborn”.

Bob’s Starting to Lose it Wife: “There must be a mistake, this was always $45.”

Uber Tech: “Truly, it was, but now you have a deductible according to my trusty computer here.”

Bob’s Now Over the Edge Wife: **Volume increased by 5-fold** “Your computer is wrong, fix it.”

Uber Tech: “Sorry Mrs. Bob, but that is your insurance copay.”

Bob’s Totally Lost it Wife: **Volume increased by 10-fold** “Well, he’s gonna die and it is your fault because I’m not paying that.”

Betty the Grandma


elderly woman sitting on brown leather chair using telephone
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Betty is everybody’s grandmother. Betty also knows that Darlene’s best friend’s brother’s cat just had to go to the vet for worms. What a scandal. But now the neighborhood knows all about it. Doesn’t matter, Betty is on top of it. Except, is she?

You see, Betty had a heart attack a couple of years ago and she’s now on a truckload of medications. But they’re so much less important than the cat in the next county. That’s the pharmacy’s job. They know everything. Like, the pharmacist is literally a wizard.

Betty: “Good morning, I need you to fill everything I need.”

Headmaster Pharmacist: “Why certainly, I will read the tea leaves and fill all you need.”

Betty: “Wonderful. I’ll be there this afternoon; did you know that Martha, who is related to Debbie, who is the sister of Bob the Builder, has scabies? How awful, truly awful. Bye now.”

That Evening

Betty: “I demand to speak to the person in charge. You lot are incompetent.”

Headmaster: “Why that would be me, care to tell me why you insult us so?”

Betty: “I asked you to fill everything I need, I most certainly did not need my metomorfomin, lispril, or my inhaler.”

Headmaster: “Well, you did indeed ask us to fill everything you needed; according to our records you should need all of those, thus, they have been filled.”

Betty: “Why I never, you should know what I need, you’re the pharmacy, that’s your job. I most certainly do not need those, I have plenty.”

Bernard the Hoarder


bearded man holding white box in storeroom
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Bernard is one of those guys you want to play Trivia Night with. Bernard has that full beard, the oil to go with it, and can rattle off every song artist out there. He plays the piano too. Bob, though, has a problem.

You see, Bernard likes to hold on to things. Like everything. He sits at an angle because of his wallet. He has to move the junk in his car to get in. Bob is giving us a call.

Uber Tech: “How may I help you today?”

Bernard: “Well hello, I have scripts to fill.”

Uber Tech: “Fabulous, what shall we fill today?”

Bernard: “I’ve got some meds in my cabinet I haven’t filled for a bit, but my bottles are low, so here you go *rattles off a handful of names*.”

Uber Tech: “Ummm…you haven’t filled some of these for 5 years.”

Bernard: “Yeah, but I must need them since they’re in my cabinet. One of them is an antibiotic, I think. I had some left and I feel awful, so I took what was left and that’s the one I really need.”

Uber Tech: “I’m gonna pass you on along to the pharmacist for an education session.”

Truly, in the pharmacy world and with regards to your own healthcare, knowledge is power. You don’t even have to really know everything but knowing where to find the answer is just as useful. As pharmacists, we’re here for you and are that resource. That being said, as the patient you should also want to be informed about what could kill you. People do not walk in the grocery store expecting the staff there to fill up their carts with items that they need. Why is the pharmacy any different?

Fixing the Problem

Let’s bring this full circle. How can the patient fix the problem with pharmacy?

Be informed

How many times does the pharmacy call patients letting them know medication is ready? For our pharmacy, it is at least 15 times per medication. Yeah, because of those pesky DIR fees we want you to pick it up. Likewise, how many ways do patients have to interact with their pharmacy now? Patients can call us, they can visit the website, they can use the app, they can visit the pharmacy in person.

Similarly, how many mailings or emails do people get from their insurance companies? Insurance regulations require a minimum interval between when they can change policies and when they must notify the patient. In most cases, you will get a mailing at least two months prior to any policy changes. Pay attention to those notices. The pharmacy does not have information about your policy, but you as the patient have all the resources you need to find out why that medication cost $346. Take Bob the Builder for example; we run into this all the time. The most underutilized resource is the insurance policy web page. If you’ve never looked at your policy’s site, go do it. You can find deductible information, drug coverage information, payment information, and more. Contrary to popular belief, pharmacies do not set the drug price. We negotiate with the insurance company for a reimbursement rate based on the price of a drug, but ultimately the insurance company determines what we as the pharmacy must charge you the patient and we are obligated by contract to charge that price.

The informed patient is usually a healthier patient. Numerous studies have demonstrated that active involvement and interest in their own healthcare produces healthier patients. For pharmacies, healthier patients mean less insurance clawbacks for missed adherence targets and more resources we can put into improving our patient care. Increased revenue keeps more doors open, and lessens pharmacy “deserts” where patients have to travel to find a pharmacy.


Know your medications

As the patient, you should be able to list off everything you take, how you take it, and why you take it. Would you go into Walmart and buy something that you had no idea why you were getting it, or even why you needed it? Why is it any different with medications? Most likely, using something you bought at Walmart wrong won’t kill you; take methotrexate daily for a few days in a row by accident or by ignorance, and you will most likely be dead or wish you were dead.

At the end of this article I’ve provided a personal health record form for download. It should be filled out and carried with you. One of the most frustrating calls I get is from hospitals trying to figure out patient med lists. Either the patient has no clue or is unconscious and can’t answer. The hospital calls me, and I can provide some meds, but in some cases the patient uses mail order. We have no clue what meds are provided by mail order most of the time. Carry a health record; it may literally save your life.


elderly woman sitting on brown leather chair using telephone
Photo by RODNAE Productions on Pexels.com

“Fill everything I need.”

— Betty the Grandmother

Remember Betty? Yeah, that should never happen. Betty may know everything going on in the neighborhood, but she can’t tell us specifically what she needs. Betty has also given the pharmacy a big clue that she is not adherent to her medication. If the pharmacy is told to fill all medications, we will fill everything that looks due. That means, if we gave you 30 tablets and you take one tablet a day and it is now 45 days out, then you should be due. Telling the pharmacy that you still have medication left on something filled 2, 3, or 6 months ago is a dead giveaway that there is an adherence problem.

Something we are all taught now is “motivational interviewing”. The concept is basically to have a dialogue with a patient to shift a behavior (e.g., nonadherence). For it to work, a dissonance has to be introduced that shows the patient that their perceived truth is different than the actual truth. Additionally, it doesn’t involve lecturing the patient; it has to be a two-way conversation with the patient doing most of the thinking and talking. I’m just there to guide the conversation to the desired end, and when successful the patient has talked their way through the problem, came up with their own solution, and realized their own mistake. Only one problem I’ve not been able to solve with this: the majority of my elderly patients jump straight to “the computer is wrong, I take it every day”. The distrust in technology with this generation is an issue that is hard to overcome; doesn’t matter that 6 months have passed after a 1-month refill. The computer is wrong. Time is relative. That or I’ve lost 6 months somewhere.

The point is, if the pharmacy is telling you it is due, it’s probably due. If you’ve got a whole slew of pills left, there is a problem somewhere. Remember, we’re going for 80% adherence. Otherwise, you’re wasting money by paying for something that is doing you no good.


Don’t be a hoarder

While hoarders may be fun to watch on TV, they’re a PITA in the pharmacy. Go right now and check your medicine cabinet. How many things are expired, OTC or prescription? Everything has a date on it that tells us it will still be 100% effective by that date. After that effectiveness diminishes over time. Now, for some medications it’s probably fine to keep using for a little while; it’s not like one day after expiration effectiveness is 0. However, its best to throw out those expired drugs. Ever had tetracycline? When it expires, it can be harmful. Same with liquid antibiotics; there is a shelf life for a reason.

Another issue: countless insurance cards. Treat them like expired debit/credit cards and shred the old card. Frankly, the worst day of the year is after January 1st when most insurance policy changes occur. We’ll run into half a dozen problems daily where we are given a handful of cards, none of which are active. Just like your car insurance and driver’s license, you should always have the most up-to-date card with you at all times. It’ll save you time, it’ll save me time, and the 5 people in line behind you will be much happier.

Get it together


blue drinking glass with water and white medicine pills
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So, long read. What does it boil down to? How do you, the patient, make a difference in your own healthcare?

  • Make a medication list. Use the link to the right to download and print a form or use the interactive form to create one.
  • Review your health policy. Explore the website for your insurance company; if you don’t know it this is a good time to figure it out.
  • Learn what your medications are for if you don’t already know.
  • Clean out that medicine cabinet.
  • Think about what you take; looking at the last date filled on your bottle does it make sense with how many pills you have left? Grab a calendar if you need to.

Remember your pharamcy is a resource, and the most accessible face of healthcare. Got a question? We’re here.

Zack
Author: Zack

Pharmacist, tech guy, pianist, lover of beer, gamer, beach bum. Probably missed something. Just assume I'm into a little bit of everything.

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