Browsing the archives for the Jp Enlarged category.

WalGreens RPh argued with this Mom. “The dose is correct. I listened to the Doctor’s Message Twice” Fortunate for the child, “My Mommy is a Pharmacist”.

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Your best chance for DIGNITY, SELF-RESPECT & INTEGRITY at your job.

California Board of Pharmacy June 24, 2015,
Public Comment on Items Not on the Agenda/Agenda Items For Future Meeting

Aglaia Panos Pharm D, preceptor at Touro University College of Pharmacy for Pharmacist Planning Service Inc (PPSI).
I would like to request a special hearing on prescription drug errors. I have become increasing concerned about my students that have been doing an internship with me for the past 6 years at Pharmacists Planning Service, Inc (PPSI). They have been telling me about the increasing number of prescriptions they have to fill in chain pharmacies with less pharmacy and technician staff and as a consequence less oversight. Meanwhile, the pharmacist’s duties have increased as they are now often required to do immunizations, scrutinize drugs more carefully for abuse as required by the DEA and Board of Pharmacy, answer questions on Medicare Part-D and spend more time on phones with insurance companies and part D plans for $4.00.generic prescriptions. Furthermore, Chain pharmacies are putting 10-15 minutes limits on getting the prescriptions out the door.
Last Sunday, June 21, I went to a WalGreen’s at 8:00 pm to pick up a prescription for my son. It was a Nystatin 100,000 units per 5 ml. This was a new prescription and I was not offered a consultation when the technician gave it to, me. I opened the bag and read the directions and said the directions do not make sense. It read to swish 25ml in the mouth then to swallow four times day. I asked to speak with the pharmacist who kept reassuring me that the recording by the doctor did in fact say that, and that she played it more than once. I asked her if she had ever prescribed such a large dose, and perhaps she should check with the doctor again. She insisted that she had done the math correctly and that a teaspoon was 5 mls and 5 teaspoons is 25 mls and she dispensed the correct amount which was 1000 mls of Nystatin, in two individual pint bottles for the duration of the 10 days.
I called the doctor that night and left a message. My son only took 5 mls that evening. The next day the same pharmacist called before 9:00AM and said the chain pharmacy got really busy last night with her having one technician to help fill all the prescriptions in the store. She went on to say how busy they there were long lines waiting prescriptions and she also had to service the drive through window. and it almost was closing time at 9:00pm. She said to wait until she contacted the doctor. She later again called to my son and told him to take only 5 ml and if he wanted to bring in the two pint bottles she would change correct the label.
One of the best selling books of the year is by Dennis Miller, a pharmacist ,called Chain Drug Stores Are Dangerous. I have a copy here and if you have not read I suggest you buy a copy. This book should be given to all state board of pharmacy members. inspectors and investigators. as required reading
I would like to thank you for considering a hearing on medication errors at your next available subcommittee hearing.
Aglaia Panos

    You can find a link to the Amazon page that has Miller’s book for sale under BLOG ROLL in left margin Heading is LINKS. JP

From Pharmacist Steve. As Always, a Pointed Guerrilla View.

Jp Enlarged

Get your own store.
Right now I am not sure about the indy route… There was a article that I posted a few days ago of a indy closing because the PBM’s were causing him to break-even or lose on 25% of his Rxs.. If you haven’t notices CVS Health and Express Scripts net profits are growing faster than their gross revenue.. Walgreens and Rite Aid are not doing that… IMO.. it is because those two PBM’s are dragging their feet in raising reimbursement prices to stores…but.. raising the price to the ultimate payor (Blue Cross/Medicare etc ) the day they happen… when prices are doubling… tripling or more on some generics… The PBM’s are raping the pharmacies.. and with CVS Health… they are raping their competition… they can’t buy WAG’s or Rite Aid out.. but.. they are putting the financial screws to indys and then coming in and buying them out.. Why do you think that Target sold out… 1600-1800 stores was not enough volume ? With 90% of Rxs being paid for by some third party… there is no pricing power..

Then we have the Supreme Court going to rule this month on Obamacare… and the premium supplements being provided in 34 states that didn’t set up their own program.. could throw Obamacare into a tail spin.. I have heard about 8 million losing their premium supplements… which means the vast majority or all will be without health insurance in another month or two…
Then we have the wholesalers rationing how much controls a pharmacy can purchase… I have heard the number of 75 indys being totally cut off by their wholesaler.. I know personally know of three .. One is a Medicine Shoppe Franchisee… by contract she was suppose to purchase 95% of all purchases from Cardinal… who is also the Franchisor… two years ago they cut off her controls – TOTALLY… then one year later they cut her line of credit in half.. and she just got informed that they are cancelling her franchisee agreement…

nevergotcaught American corporation are – IMO – operating under the 11th commandment … nothing is illegal until you get caught …or the 12th commandment.. if you can pay the fine… do the crime…. stock price and bottom line is all that matters.


Written by Kay Geers, a pharmacy owner in Missouri and one of the original Galvestion Group that founded THE PHARMACY ALLIANCE

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This is long, but Kay put a lot into it. Respect her as a person who goes way beyond whining and look it over. JP

Honorable Chris Kelly
Missouri House of Representatives

Dear Mr. Kelly,

I own the Ashland Pharmacy in Ashland, MO. You have been in here a couple times before the elections. I’m glad to see that you won.

I have a couple issues that I have no recourse to fix except to contact the elected officials of this area.

Firstly, the Medicare Modernization Act of 2003 (MMA) has severely hindered the provision of pharmaceutical care for many patients in Missouri. Close to 5% of small independent community pharmacies in the country have closed due to this Act. I’m assuming it holds true for Missouri as well. These small pharmacies are usually in towns with populations of less than 20,000 people and a higher percentage of Medicaid, Dual Eligible and Medicare patients. Our population here in Ashland is around 2200 yet the area surrounding Ashland, as you are probably aware, has a population of around 15,000 people.

Not only are these pharmacies closing, but the ones that are still in operation, including us, have terminated our participation in several Medicare D plans due to low-ball contracts that we are not allowed to negotiate. Once we have terminated participation, most of my patients (elderly) will be required to drive to Columbia at 70mph to Wal-Mart and wait 2 hours for their prescription to be filled. The patients that choose not to drive to town are sent information on Mail-Order pharmacies that are usually in another state.

The most painful part of the MMA is that the Pharmacy Benefit Managers (PBMs) are getting away with the goose that laid the golden egg. The PBMs wrote the bill, coerced several members of Congress to pass it and wrote into the bill that there is no Government oversight at all in the program. In essence, they can do what they want and the government cannot even look at their books to see if they are hurting or helping the healthcare system.

The Centers for Medicare/Medicaid Services (CMS) has set standards for the PBMs to follow but not set out what exactly they must do. The PBMs pay us a small cost and small dispensing fee to fill the prescription and charge the Insurance Company a greatly exaggerated price. They make more money on a prescription than we do and we carry all the overhead. The average pharmacy pays close to $10 to fill a prescription, not counting the cost of the medication. I would like to meet with you to discuss what is becoming a serious problem.

Jim, here is my take on this.

The Medicare Modernization Act that created the Medicare D Prescription Program has been causing hardships on independent pharmacies since the program was instituted in 2006. In the beginning, there were a lot of eligibility problems with “True Out of Pocket Expenses and Low Income Subsidy patients. It took about 6 months to get the payments straightened out and paid correctly. It took several hours on the phone to correct these problems. Since then, the biggest problems that I see are that some pharmacies are not getting paid in a timely fashion and the reimbursement rates and MAC pricing are discriminatory against retail pharmacy. There are also little problems that are adding up to being big problems over time, like the pharmacies having to pay transaction fees to get the pharmacy claims to the PBMs, and having to pay for e-prescribing prescriptions and possibly having to pay for track and trace technology.

What has happened to our government for the people? Where does it say that the government is for large corporations forcing little businesses like mine out of business? Where were the Congressmen that WE elected when we needed protection from these large interests? They were all on the side of Big Business, the Big Business of making medications (drug companies) and processing prescriptions for insurance companies (Pharmacy Benefit Managers). Big Business can afford to pay each legislator thousands of dollars to vote in their interest. We cannot.

Did you know that the Medicare Modernization Act was passed in the middle of the night with some strong arm lobbying occurring? I’m not sure if the bill would have passed had there not been coercion on their parts. I’m sure lots of money changed hands somewhere in the process. Today, several congressmen and congresswomen that voted in favor of the raping we are now taking are holding high paying jobs with the companies they were voting in favor of.

This whole process has been a travesty for our country. As far as I’m concerned, I’ll never have the faith in our form of government that I had before. I have thought of leaving the country for Borneo to raise Orangutans or to Nigeria to help with orphaned Elephants.

All I’ve ever wanted to do is help my patients, make a decent living and retire peacefully at 50 or 55. Is that too much to ask? Every day I have to bump up against either not getting paid appropriately for a prescription or having to spend hours on the phone with a PBM who has outsourced it’s help desk to India trying to get a medication covered.

I did not go to Pharmacy School to become an insurance adjuster. My opinion is that if they want a different drug they should call the doctor themselves. We should not be involved in that process at all. We should be able to fill prescriptions that are approved by the PBM and doctor without having to jump through hoops to do it.

Now back to transmission fees. I found an article in Drug Topics in 1989 stating that it cost the PBMs $5.00 each to process paper claims. This is the same year that electronic processing became rampant. By calculating the cost difference between us paying transaction fees and the PBMs paying to process paper claims I have come up with some staggering numbers.

Given: processing 1,000,000 prescriptions/day
Average person takes: 8 rx/day-100% insurance
Patients 1,000,000 rx / 8 rx/patient= 125,000 patients
Transaction fees set at $0.10 per claim
Paper Processing would cost $5.00 in 1989
Interest 0.8% per day
Average RX costs $50.00
Average copay costs $8.00

The pharmacy sends 1,000,000 prescriptions to the PBM daily. The pharmacy pays $0.10 for each claim submitted totaling $100,000. The PBM would have paid $5.00 per claim to process. The PBM saved $5.00 per prescription = $5,000,000.

Just taking into account 1 day’s worth of business for a PBM they would have saved $5 million by not processing paper and we would have paid them $100,000 to process electronically. They netted $5,100,000 in one day.

Now let’s extrapolate that to a month and year.
30 days x $5,000,000 = PBM saves $150,000,000 by not processing paper.
30 days x $100,000 = Pharmacy pays $3,000,000 Net to PBM $153,000,000 per month
$153,000,000 for 12 months = $ 1,860,000,000 to PBM for 1 year
BUT! The pharmacy had to pay $3,000,000 x 12 months = $36,000,000 to process them electronically.

To me that’s a rip off. Why should we pay to have claims sent to them so they can have a computer process them?

There’s more!!!
CMS pays each PBM $68 per month for each patient to manage their drug benefit.
They make interest by holding our money for 14 days. (Figure 0.8% per day)
The patient pays $26.39 each month as a premium.
The insurance companies pay the PBMs $1.00 per claim for administrative costs.

PBM gets:
$68/patient/month x 125,000 patient x 12 months = $ 102,000,000 from CMS
$26.39/patient/month x 125,000 patients x 12 months = $ 39,585,000 in premiums
$1.00/ claim x 1,000,000 claims = $ 1,000,000 for Admin costs
Paid by pharmacies in transaction fees = $ 36,000,000 per year
Saved by not processing paper = $ 1,860,000,000 per year
Total $ 2,038,585,000
Yes, that’s $2 billion dollars profit they received for processing claims of which we paid them $36 million to do it. Even if we take out the money they save by not processing paper, their profit is $ 178,585,000 per year. That’s only 1 million prescriptions per day. I’m sure there are many more millions that are processed and many more PBMs.

Now let’s count the interest they make by holding our money for 14 days.
The average prescription costs around $50.00. Let’s set average copay at $8.00 so PBM will owe us $42 for each prescription.

1,000,000 rxs x $42/rx = $42,000,000 for one day x 14 days = $588,000,000 the PBM owes pharmacy.

$588,000,000 x 0.8%/day = $4,704,000 for 14 days = $65,856,000

Extrapolate this out to a year = $1,716,960,000

Grand Total Profit to PBM per year $3,755,545,000

These same 1,000,000 prescriptions per day would have cost us 365 * 1,000,000 = $365,000,000 x $0.10 trans fee = $36,500,000. That’s counting the interest we lost to let them hold our money for 14 days and on average we lose $5.00 on every prescription due to the PBMs not paying us a dispensing fee that covers overhead. So there’s $5,000,000 x 365 = $1,825,000,000 + $36,500,000 = $1,861,500,000 the pharmacy has paid and lost (in essence) to process the claims.


If the PBM processes 1 mill rx/s per day every day for 1 year they would earn a grand total of $3.755 billion, but the pharmacy has lost or paid $1.861 billion to do it.

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The Guerrilla Pharmacist Goes INTERNATIONAL

Jp Enlarged

This is the message received from a Canadian pharmacist. Maria Gutschi. The package of GOODIES contained a copy of THE COMFORT TRILOGY, Editions 1, 2, 3 of THE GUERRILLA PHARMACIST and promotional materials. ie. the coming of Rex Guevara. With Snehal back in the UK, we have two international GUERRILLAS.

The picture is the first one up when you enter MARIA GUTSCG on the Search Line at Big Images. Our Maria? Probably NOT, but a compelling young woman. THis will be OUR Maria whenever I think of her.

Think about this: MARIA GUTSCHI HUNTED US DOWN. She asked me if a Canadian could jump on our speed boat. Yes, of course. Here is her Email to me.

From: Maria Gutschi (
Sent: Fri 6/05/15 4:04 PM
To: Jpgakis Plagakis (

Hi Jim
I just received your package of goodies yesterday, and am very impressed with the content and and even better the tone.

I am sending you a money order since US citizens cashing a Canadian cheque is problematic and often not accepted. I hope that is acceptable to you.

Here in Canada the Big Chains are flexing their muscles, but pharmacists are striking back. However, I am not sure this will make a difference if the colleges (i.e. Boards) of pharmacy do not respond. Some provinces are better than others.

As you can guess, the president for Rexall is from the USA.

HOWEVER, I believe the reason for pharmacy being the in condition it is in, is likely because of our personalities and work environment. Some Canadian researchers have done great work to delineate this.

Pharmacists are:


Avoid conflict

Defer to Authority

Want to be Nice rather then Right

A perfect population for the Masters of the Universe to exploit.

Keep up the good work

Maria Gutschi


APhA Finally Makes a Statement. Straightforward Reporting. WHERE IS THE POLICY STATEMENT?

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Under pressure: Performance metrics in chains may affect safety 
June 01, 2015
pressure that many chain pharmacists feel

“It’s all about numbers. That’s all they care about. You’re there and on your feet for 8 hours, and you’re at the mercy of the volume.”

The speaker was Bill Bradshaw, BSPharm, a semiretired former Walgreens pharmacist from Arlington, TX. He was describing the pressure that many chain pharmacists feel as they try to meet prescription fill-time goals while fielding phone calls, managing auxiliary staff, and keeping up with immunizations and customers’ medication therapy needs. 

The yardsticks companies use to evaluate how well pharmacists manage these complex professional duties are known collectively as “performance metrics.” It is a phrase that pops up frequently in pharmacists’ blogs, tweets and other online forums—and not usually in a positive way. A common thread is that use of metrics to help speed prescription flow often runs counter to good pharmacy practice and heightens the danger of increased medication error rates.

“It’s time pharmacists are protected from this metrics system,” wrote Katrin Olavessen-Holt, commenting on a Pharmacy Today Facebook posting of a March 3, 2015, CBS Sacramento article headlined “Call Kurtis: Pharmacists Concerned Employer Pressure Leads to Prescription Errors.”

“Speed and money over safety. Never a good thing!!,” added Carrie Wellman Arbuckle. The article describes the potential downside of performance metrics in California. The Today posting drew more than 325 “likes” from Facebook followers.

Major chains: Different view

The three major pharmacy chains have a different view of the metrics they use to evaluate pharmacy performance. And they cite their efforts to smooth pharmacy workflow and ensure customer satisfaction and safety. 

CVS/pharmacy spokesman Michael DeAngelis responded to Today ’s request for comment with a statement saying that CVS, like other companies, “measures the quality and effectiveness of the services we provide to ensure we are meeting our customers’ expectations and helping them to achieve the best possible outcomes. Our systems are designed to help our pharmacists manage and prioritize their work to best serve their patients.”

Jim Cohn, a Walgreens spokesman, said in an e-mail that “quality, safety, and accuracy are our top priorities, and we make it clear to our pharmacists that they should never work beyond what they believe is safe, in their professional judgment.”

At Rite Aid, spokeswoman Ashley Flower stated that the chain was “highly committed to patient safety and care,” adding, “We have a strong safety record because of our ongoing education and training for pharmacy associates as well as our continued investment in technology.” Rite Aid, she said, uses “various metrics to ensure we are consistently delivering a superior customer experience and helping those we serve achieve the best possible health outcomes.”

The safety equation

While the chains do invest heavily in new technology systems, workflow design and training programs to meet the expanding demands on pharmacists’ time, there is always the risk that ever-increasing prescription volume and bottom-line considerations may tilt the safety equation to the negative side. Moreover, policies created at the top to ensure that pharmacists are well equipped to handle both dispensing and patient care responsibilities can encounter obstacles as they filter down to supervisors, who themselves may be under pressure to perform. 

David Nau, BSPharm, MS, PhD, president of Pharmacy Quality Solutions Inc., noted that many studies in the past had shown an association between volume of work and medication error rates. “One thing that makes a difference,” he said, “is that the complexity of work, or the workload issue, is intertwined with staffing and processes. Part of the issue of reducing distractions of pharmacists is finding the right balance of workload and the pace of work.”

Some pharmacists maintain, however, that the balance can be thrown off kilter by technician staffing that fails to account for the high number of prescriptions that pharmacies are called on to dispense. “They keep cutting tech staff hours, regardless of the volume,” said Steve Ariens, BSPharm, national public relations director for the Pharmacy Alliance, a pharmacists’ advocacy group. He likened it to the slave galley rowing scene in the 1959 movie classic Ben-Hur. “Rowing faster and faster: that’s pharmacy,” he said.

Bill Bradshaw said it was “practically impossible to do your job the way it was supposed to be done with the help that they gave you.” At one Fort Worth, TX, Walgreens where he worked, “it was very intense,” he said. A doctor he consulted told him that he was suffering from post-traumatic stress disorder. He finally left the pharmacy after about 3.5 years. During that time, he said, “That one store had five pharmacy managers. They just couldn’t handle it.”

‘From green to yellow to red’

One widely used performance metric tracks prescription dispensing time from customer drop-off to pick-up bin. The limit is often set at 15 minutes. David Stanley, BSPharm, a California pharmacist who worked for both Rite Aid and Walgreens, told Today that both chains used computer clocks to monitor the time. The clocks “would slowly turn from green to yellow to red,” he said, “depending on how quickly prescriptions were getting out the door.” 

Stanley added that he saw “nothing wrong” with metrics in general, particularly if used to evaluate quality, but “the problem I’ve run into is that they choose their metrics poorly. And they lose sight of the goal, which is happy customers and pharmacy practice the way it is supposed to be practiced.”

He described a prescription label policy that Rite Aid had in effect when he worked there several years ago. “We were told never to print more than five labels ahead,” he said, but “we had our own way of doing things, which was to print labels for as many prescriptions as we could and get them as close to being filled as we could. That way, when it was slow, you could work on the label pile and basically get a few out the door in between customers. It was a great system,” he said. “When we started following their directive, it actually slowed us down and it worked against their larger goal of happy customers and quality prescriptions.”

“They didn’t want to hear it,” he said.

Lawsuits against chains

Some pharmacists have brought lawsuits against chains. Joseph Zorek, BSPharm, for instance, has a current suit against CVS Health. He told Today that performance policies and “intimidation” he encountered as pharmacist-in-charge at a Harrisburg, PA, CVS pharmacy, led to various physical ailments and disability—the basis for his legal action.

Zorek described one metric CVS used to evaluate performance. “They wanted us to sign up all patients to ReadyFill,” the chain’s automatic prescription-filling program. He said his patient base consisted of a higher-than-average number of senior citizens, who “felt much more comfortable being in charge of their own prescriptions. As a result, my metric for signing up people was low.”

Zorek added that he felt he could “play ball” with most of the other requirements. “They had a 15-minute constraint” for measuring prescription fulfillment time. “That was fine,” he said, “but normally Murphy’s Law would set in, and something would go wrong.” Describing a hectic pharmacy scene in which techs were often called away to take over busy cash registers and pharmacists were forced to handle calls on 10 different telephone lines, he said, “Your mind was in too many places. The error rate started to go up. We were making stupid little mistakes: using the son instead of the father, wrong address, improper doctor. ”

Still, Zorek said, he “enjoyed the pace and working with people”—that is, until the company began cutting technician hours. His wife, Paula Zorek, who also worked at CVS, as a technician and technician trainer, said that in 2011, every store was losing technician hours. “They upgraded the computer software,” she said, “and they thought they could do more with less. It didn’t work out that way.”

2012 ISMP/APhA survey

Anecdotal complaints about the use of metrics and pharmacy workload have circulated for years. In 2012, the Institute for Safe Medication Practices (ISMP) launched a survey in collaboration with APhA. One aim was to assess the impact of prescription fill-time guarantees on pharmacy safety. A total of 673 pharmacists responded, most of them from chain drug and grocery/mass merchant pharmacies. A major finding was that 83% of those working at pharmacies with advertised time guarantees believed that the guarantees were contributing to dispensing errors. 

In response, the National Association of Boards of Pharmacy (NABP) issued a statement resolving that NABP “assist the state boards of pharmacy to regulate, restrict, or prohibit the use in pharmacies of performance metrics or quotas that are proven to cause distractions and unsafe environments for pharmacists and technicians.” 

Fewer errors: One solution

Are there solutions for reducing the potential safety hazards of performance metrics and prescription time-filling guarantees? Nau, whose company supports health plans, PBMs, and community pharmacies in their efforts to measure and improve medication use quality through its EQuIPP program, said that “we actually find that when pharmacies synchronize the refills of patients on chronic medications, it helps to smooth out the workflow and balance the ebb and flow of volume throughout the day.”

That should help lead to fewer errors, he noted. He also said that as “pharmacists do more to be proactively engaged in managing their patients’ regimens, it will help to balance the workload. So when issues arise, that communication will help to identify potential issues before they become a major event for the patient.”

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