Posts tagged ‘pharmacy’

The Chronic Pain Conundrum

Extreme Rx

I would have a lot of questions for both the prescriber and the patient. On the surface, with no details, this really smacks of diversion.

One of my chronic pain patients, “Alpha,” moved to Florida. About a year before that,  I had received notification from the pharmacy chain management where I worked that it would be prudent for me to do a bit of CYA for myself and the company. I was to speak to the prescribers for my chronic pain patients and make notes in their profiles as to their diagnosis. In other words, why are these patients taking so much pain meds? When Alpha found out about this, she accused me of calling her a drug addict and causing her doctor to question her need for the meds. [Not her Rx shown above]

About two weeks ago, I received a phone call from Alpha. She was having trouble finding a pharmacy that would fill her prescriptions in Florida. I referred her to my successor at the store where we had become acquainted. I’ve been gone from that pharmacy for two years. Her daily dose would be fatal for a patient who had not built a tolerance for such high doses. Her doctor requires regular lab tests to ensure she is taking the medication.

Yesterday, I refused to fill a prescription for a “patient” who is on a similar regimen of drugs. We’ll refer to him as “Beta.” His doctor doesn’t do blood or urine tests to confirm compliance.  His doctor requires cash payments for office visits at the time of the visit. This patient drives a new Mercedes. Yesterday, as he often does, he wanted his prescription filled a week early. He became unruly when I pointed out that the doctor himself had put on the prescription when it could be filled.

Pharmacists from around the country report similar occurrences in their practices.

10,000 Baby Boomers turn 65 every day.

10,000 Baby Boomers reach age 65 every day.

Both scenarios are commonplace now as baby boomers turn gray and average from  three to five prescriptions (not all pain meds) as daily maintenance. It’s apparent that boomers have a lot of pain. This point was driven home by two noteworthy events:

  1. pain management clinics began to spring up around the country and…
  2. The government made it easier and quicker for pharmacists to order schedule two controlled drugs. (Amazing, isn’t it? The government made something easier?)

Then I met Betty Lou (my favorite generic name) but to be consistent here, she will be “Gamma.” She’s been my patient now for a couple of years. When she first started doing business at my store, her doctor confirmed that she was a terminally ill cancer patient. She’s been terminal now for over two years. She takes three different narcotic pain meds, Ritalin® in the morning, and sleeping pills at night. She takes meds for nausea and constipation. She’s obese.

And this represents only three of the hundreds of patients we see on a weekly basis.

Now meet patient “Delta.” Delta comes in regularly with prescriptions for 240 Ultram®, 180 Percocet®, and 90 Dilaudid® tablets(all generics.) Every month, Delta presents that month’s prescriptions a few days early. Delta’s chief complaint is “Every time I come into this pharmacy there’s a problem.” The recurring problem is that Delta wants early refills every month. Delta’s doctor writes the date each prescription can be filled into the instructions.

Some of the patients who seem legit, take so much, I wonder. Are they really taking that many tablets?

Some of the patients who seem legit, take so much, I wonder. Are they really taking that many tablets?

Finally, patient, “Epsilon.”  Epsilon sees a different doctor every week. Sometimes the doctor is from out of state. I’m not aware of any pharmacy in our area of the state that will fill an out of state prescription for schedule two controlled substance.

It’s disheartening to see bona fide long term pain management patients become addicted to drugs and then watch that dependence change their behavior to the point that we cannot deal with them rationally.

Another day in the life of a pharmacist.

To be continued tomorrow, HERE.

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Acknowledgement: Free lance writer and investigative reporter, George McGinn contributed to this article.

Changes in Healthcare Delivery are Dangerous to Your Health

Pharmacy student, James Herbert joins us today.

Pharmacy student, James Herbert joins us today.

Our guest blogger this week is James Herbert, a Pharm D Student at South College School of Pharmacy, Knoxville, TN. He is a Husband, Father, Doctor Who fan, science fiction fan, philosophy-theology aficionado, and ex-IT guy with dreams of using informatics and technology to enhance pharmacy’s role in improving patients lives. He says, “I’m just a regular guy livin’ the dream because in the end aren’t we all?”

His topic addresses a situation begun decades ago and is now coming to a head. We introduced this subject last week with an article regarding the re-branding of patients to customers. Herbert believes there’s more to it than just semantics.

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James Herbert

James Herbert

A paradigm shift in healthcare begun years ago, speeds toward the downgrade of the patient to a statistical economic construct.
Patients are now being referred to as customers.
This is a dangerous shift that moves the focus of the patient’s medical needs towards the consumption of goods and services. Consumption of services does not require the relationship between patient and healthcare provider necessary for patient care. The purpose of healthcare is to provide appropriate care to patients. This shift away from the fundamental principle of personal attention is detrimental to the public health.
“Customer” is an economic term: A party that receives or consumes products (goods or services) and has the ability to choose between different products and suppliers.1 A patient is a person who has a medical need. In times of an emergency a patient does not have the luxury of choosing who provides their care. In cases of extreme emergency they have no say what so ever. Patients do not consume the “goods” and “services” of healthcare in the same way they would in a traditional retail environment. You will not see patients lined up at a hospital door on black Friday for example.
Dorland’s Medical Dictionary (2008) defines patient care as the services rendered by members of the health profession and non-professionals under their supervision for the benefit of the patient
Taking care of customers is commonly called customer service. “Customer service is a series of activates designed to enhance the level of customer satisfaction –that is, the feeling that a product or service has met the customer expectation.”2
Customer satisfaction is measured by the satisfaction survey. Here is where the disconnect begins
A survey, by its very nature, limits itself to the chosen parameters. That is to say that there are “buckets” that are being weighed as they are “checked off” in the survey. It is in this way that the customer is reduced to a set of statistics. In surveys, the person is irrelevant, it is the data that is important. Chosen members of management chose the parameters.
Data identifies trends and trends can be impacted by a series of scripted efforts. These efforts are called metrics. Metrics reduce customer service to a series of equations. CVS uses Triple S and KPM metrics3 in order to quantify and improve service performance. Customer expectations can be manipulated in scripted measures. Sitting down with a customer influences their perception of the amount of time spent with them4. Adding key words or phrases to encourage additional purchases is another scripted method of providing customer service (See CVS Pharmacy Business Metrics Paper)
Pharmacy may be measured by its Triple S and KPM or similar metrics but for hospitals to be reimbursed for providing care to those with Medicare/Medicaid, HCAHPS is the golden standard. Press Ganey is the leading provider of patient satisfaction surveys designed to help meet the HCAHPS requirements.

The manipulation of satisfaction scores may have nothing to do with providing safe and ethical healthcare. In one case a physician was able to achieve a 7% improvement in his satisfaction scores by prescribing an antibiotic to all his patients who complained of a cough, sore throat or sinus headache5. Managing low scores can lead physicians to prescribe powerful opiates for toothaches6. Healthcare professionals under pressure to meet metrics, forego patient care to perform customer service. The result is that most satisfied patients tend to be those who have higher healthcare cost, drug expenses, and most shockingly, have higher deaths rates than those who do not feel satisfied with their care7. The customer purchases their “good” but they may not get care for their health.
The retail pharmacy chain is the end game when customer service once and for all trumps patient care. In the retail setting, “wait times”, scripts per hour, and profit margins are king7. The pharmacist as healthcare provider is no longer part of the business model. Overwhelmed with hundreds if not thousands of script per day and skeleton staffing the pharmacist’s role is reduced to that of a dispensing machine. The result is they are not perceived as healthcare professionals. One woman demanded: “Please just do your jobs and fill what you see and stop trying to make yourself something you are not”9. In retail chain pharmacy healthcare is not important. Customer service is. Customer service quantified by metrics.
When results are all that mater then there is no “person” behind the customer or patient. They have been dehumanized. All that is left is the data. People do not get treatment. Data gets manipulated. Customers are not getting service. Data gets manipulated. When all that matters is the data, then the ends justifies the means. Metrics and surveys, by their very nature, dehumanize people.
The future of healthcare is freighting if the focus does not turn back to personal patient care. A therapeutic relationship addressing a patient’s medical need with personal and individual care, trust, and understanding. This includes a healthcare provider who has a specialized set of knowledge and skills that are not available on website, a television ad, or a talk show.
When raw, sterile numbers take precedent over warm flesh, people are no longer in the equation.

 

Without people there is neither health–nor care.

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References:

# http://www.businessdictionary.com/definition/customer.html
# Turban, Efraim (2002). Electronic Commerce: A Managerial Perspective. Prentice Hall. ISBN 0-13-185461-5.
# CVS Pharmacy Business Metrics: http://s3.documentcloud.org/documents/472510/250510-rx-tg.pdf
# Simple tips to improve patient satisfaction http://www.medscape.com/viewarticle/743875?src=mp&spon=25#vp_2
# Patient Satisfaction is Overrated: http://www.medscape.com/viewarticle/821288
# Why rating your doctor is bad for your health: http://www.forbes.com/sites/kaifalkenberg/2013/01/02/why-rating-your-doctor-is-bad-for-your-health/
# Patient satisfaction linked to higher health-care expenses and mortality http://www.ucdmc.ucdavis.edu/publish/news/newsroom/6223
# Pharmacists: Corporate greed putting patients at risk http://www.khou.com/story/news/investigations/2014/11/06/iteam-prescription-errors/18591573/
# LETTER: Pharmacists aren’t doctors http://www.courierpostonline.com/story/opinion/readers/2014/11/17/letter-pharmacists-doctors/19044977/

The Customer May Always be Right, But the Patient Is Not

Last week a new acquaintance asked me what I do for a living. My reply, “I spend my day telling people things they don’t want to hear. I’m a pharmacist and I deliver the news that  “your co-pay is much higher than you expected,” “your insurance company requires a prior authorization,” “your prescription was out of refills and your doctor has not responded to our request for a new prescription.” The list of examples goes on and on, but these are by far the most common.  People have high expectations of me and my department to make sure they leave the store happy and on the road to recovery from the ailment that brought them into the store.

Stew Leonard owns one of the most successful grocery stores in the world. Does his policy work in every situation?

Stew Leonard owns one of the most successful grocery stores in the world. Does his policy work in every situation?

Years ago, a syndicated columnist stated in no uncertain terms “The customer is NOT always right.” The article continued with the author’s evidence to support the claim. In retail sales, the age old standard is a difficult hurdle to overcome. In pharmacy it’s almost impossible. Once a shopper complains to a member of management outside the pharmacy, it’s a sure bet the manager will side with the customer—unless it’s a patient requesting something the pharmacist is prohibited from doing either by law or regulation. The distinction of roles they play once they enter the portal of a retail pharmacy is blurred. Sometimes, the clarity of a sharp focus is never achieved.

A simultaneous reference(customer/patient) to the people who shop in stores that contain a pharmacy became noticeable back in the 1970’s.  Was this duality the precursor to changes we see in the perception of consumers today? Are these shoppers  customers or patients—or both?

This labeling of shoppers took on more prominence with the rise in popularity of chain drug stores in the late twentieth century.

When pharmacists (usually independents) began leasing space for a pharmacy inside department or discount stores (such as Walmart’s precursors like “Gibson Wholesale”) the change  in,  shopping nomenclature picked up speed as well as consumer awareness of the trend.

Pharmacies are now being paid for talking to patients.

Pharmacies are now being paid for talking to patients.

Contemporary retail practice settings such as a prescription department in a grocery store or Walmart, continue that same tradition with shoppers being both customers and patients. I worked for Walmart for 7 years and by the time I left, we had to document counselling encounters in the computer—yet another conversion of a patient to a number.

Another significant event in the change in perception of shoppers was the influx of non-pharmacists into upper level management of both hospitals and chains. [Historical note: Eckerd Drugs (which no longer exists) had a chain of command of pharmacists supervising pharmacists from store level all the way up to the highest echelons of corporate management. The Sr. VP of Pharmacy reported directly to the CEO. Non-pharmacist management types could influence pharmacy only via him. Those days are gone with the wind. By contrast, the top pharmacy position at Walmart is a medical doctor(or was a few years ago.) ]

Retail pharmacists are now required by law to offer to counsel patients on new prescriptions. The requirement comes not from a concern for customer service, but from the government wanting patients who received government funded medication to use it correctly. Uncle Sam wants the most bang for his buck. Insurance companies now reimburse pharmacists for these same “cognitive services.”

Simply stated, insurance companies want pharmacists to talk to their beneficiaries and, just like our Uncle, get the most bang for their buck.

Many pharmacists complain that the reimbursement is not commensurate with the time involved. Many patients don’t want these extra services. They just want their prescription so they can get home, eat supper, and watch television. Perhaps they don’t mind being just another number. Such a mindset could be dangerous to their health.

Whether they consider themselves customers or patients, the shoppers I serve have one thing in common;

they’re all on drugs.

Forty by Fives

February 20 of next month will mark the fortieth anniversary of my liscensure as a pharmacist. I’ve been counting tablets and capsules by fives, for four decades.Counting Tray

I earned a B.S. in pharmacy at Northeast Louisiana University [now known as the University of Louisiana–Monroe] and graduated in December of 1974.

It’s been an interesting forty years, including a seven year hiatus in which I left pharmacy for Dale Carnegie Training and New York Life. I returned to pharmacy in 1992.  For “About Me” descriptions in the social media, this is what I list: “Husband, father, grandfather, pharmacist, photographer, and published author.”

Over the next twelve months I’ll post a few blogs with reflections on my career along with some guest blogs by other pharmacists and health care folks I’ve met along the way. In addition, there will be a few blogs to chronicle the my evolution from small town farm boy to small town pharmacist.

Maybe someone will find them of interest.

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