Welcome to the Pharmacy, shall I wipe your nose for you?

[partran]

So today I ran up against perhaps my biggest single pet peeve of human behavior at work. Well, at least in regards to work. Picking my biggest pet peeve of all, well it's like picking your favorite tree from a forest. I have so many...

The one in question though, has to do with the expectation of care. I don't mean the expectation of prompt,

Comments

[partran]

That's a topic I've thought about putting a rant up about and will soon, but it's an issue of volume, interruptions, insurance, interruptions, staffing, interruptions, bottlenecks, and interruptions.

Say Patient A brings me a prescription, a single item prescription with no errors on it and a simple count/bottle/label action. If I don't have any other prescriptions or anything else, I can scan the prescription into the computer, type it, bill insurance (which is mostly automated), review the typing, print the bag leaflet, fill the prescription, review the product in the bottle, bag it and sell it in less than 5 mins. That's pretty standard.

Now that's 5 mins. The pharmacy I work at does about 280-300 a day, so we'll do 300 for ease of mathematics. That's 1500 minutes (5x300) or 25 hours.... So that's more than the 11 hours we're open.

I have staff that can do a lot of these tasks at the same time. Tech A types and bills insurance, Tech B fills, Pharmacist A both does typing and product review, Tech A sells the prescriptions. If this is going smoothly a patient can drop off a prescription and have it filled in 10 mins.

Now... I average six phone calls an hour, I have to check voicemails, I counsel patients, I call doctors in regards to errors or illegible prescriptions, I sit on hold... and I sit on hold, and I sit on F'ING HOLD... So from the pharmacist standpoint, I am the pinch in the hourglass. If I counsel for 10 minutes because it's a new inhaler that's 10 mins that no prescription can progress along that line. If I'm being told by some medical assistant that they don't understand why I can't give a patient amoxicillin 450mg capsules because they don't exist, when their calculator says they should take 450 mgs, or any of the other thousand things that go on, things slow down. And this is just assuming everything is ticking over smoothly. If a tech is late, or sick, or we have a problem customer, or if we have more people show up to pick up prescriptions and I have to take someone off the fill line to help ring at the register, things slow down a lot.

More staff might fix this, but California has laws on how many techs there can be per pharmacist and right now with reimbursement rates being just gutted this year with Medicare, there's no money keep the techs we have much less add more.

Some time ago, The Angry Pharmacist, www.theangrypharmacist.com made a post about how a pharmacist's job is all about interruptions and it's true.

And this all assumes uncomplicated, unscrewed-up prescriptions that I don't have to call on, or that the patient's insurance works, or that the patient's insurance covers that medication, this assumes this for every prescription that comes into my pharmacy. So if Mr. Old Gummer's prescriptions don't go through on his Medicare Part D, or he's in his donut hole and spends 20 mins yelling at my staff because the gov'ment should pay for all his drugs because he's old and paid in when he worked, that delays every other prescription that day 20 mins.

[otterdoc]

Yeah, see, this is the sort of shit that isn't apparent when I'm standing on the client side of your fishbowl. :) You get just as much interruption and hassle as I do when I'm trying to see appointments. It's often me as the bottleneck due to a lot of the same kinds of problems that you're describing as part of your own day. I have a LOT of sympathy for that kind of stuff, so I'm glad I didn't ever flip out about the wait. Frustrated? Yeah, but probably not as frustrated as the pharmacy staff. And now I know. In a lot of ways, it's much easier for us. Everybody pays out of pocket for damn near everything.

I don't use any chat programs (other than the MUCK, which I'm rarely on anymore). I'm an internet curmudgeon that way. Cut my teeth on raw telnet MUCKing, after all. ;D

-M.

[partran]

A pharmacy can be up to their necks in work, hours behind on the prescriptions due that day, and everyone on their last nerve, and the place look quiet and orderly, it's weird like that. It can be insanely busy and on the other side of the counter they see people wandering quietly about their work.

Yeah, insurance is a real gem to deal with. The silliest thing they do is that insurance cards don't have any standard layout or system for where the information goes. It's as much an art as anything to know how to handle insurance cards patients hand us. Because big companies like Blue Cross or Aetna or others farm out their prescription coverage and PBM (Pharmacy Benefits Management) services to companies dedicated to them, the numbers that I use are totally different from the ones the doctors use, and sometimes they don't even print all the information we need. A good tech can look at a card and remember what it is, if it's one we've dealt with before, and I get lucky more often than not when I do it. That process, dealing with the many and varied insurance cards and companies, is the one that takes the longest to teach new techs and is a daunting procedure. And state-managed prescription coverage, and Medicare part D all do different things too and can be a real terror. Here in California the state run prescription coverage is managed by the counties and varies widely from county to county. It's a tangled mess.

[otterdoc]

I often feel that the 'out of pocket' cost of veterinary medicine is my biggest hurdle in practice. We often have to make decisions based on the client's available funds. There's an illusion, I think, that human medicine is in a better position.

You have my honest sympathy for having to deal with this system on a daily basis. I'd flip out.

-M

[partran]

Yeah, in vet medicine you have a more pointed example of cost vs. benefit of health care because the costs are right there for the patient. It's hard and seems callous making decisions about health an prolonging life based upon money and costs, but it's necessary even in human medicine. This is where formulary decisions and restricted drug utilizations show up in my practice.

[partran]

Oh, and when I see easily preventable problems that throw these delays into my workload over and over, for example handwriting that looks like the doctor shoved the pen up his ass and squat over the pad to scribble it, it makes my blood boil.

At the best it's just inconsiderate and a time-waster... at worst, well, yeah... With crap handwriting warfarin 1.0 mg and warfarin 10 mg are pretty much identical and one puts the patient in the hospital and the other's the right dose.

There are others, but bad handwriting is a big irritant of mine, as is all the "piss-poor-communication" group like mumbling into the phone, talking like it's a race to give me all the information, or making your nurse with an impossibly heavily accent call everything in.

[otterdoc]

I try pretty hard to write legibly. My big problems with the pharmacy are generally one or more of the following:

-The drug guide I use does not list currently available mg or mg/mL options for various drugs.
-The pharmacy staff tells my clients that 'it doesn't come in that strength' when what they mean is they don't CARRY that particular mg size.
-They change my orders without my consent.
-They call to ask if the patient can have something 'cheaper' that's 'just as good' when in fact it may be a far worse choice for a veterinary patient. (Like Cipro. It's damned near useless in animals, but when I script for Augmentin for a UTI, they call to ask about cipro 50% of the time.)

Problems getting ahold of my own medications typically result from the doctor's office fucking something up, or scripting something that's the result of drug rep visits that week to the office. Annoying as hell.

-M.