George Fullovit, the CEO of PriceWorld Drugs

This is easier than e-mailing the pdf.  The first 11 pages of  “The Rebels of Comfort” without the illustrations.

“You don’t need a weatherman
to know which way the wind blows”
Bob Dylan

The Rebels of Comfort.
Lights Out!

By

Jim Plagakis, R.Ph.

Copyright by Jim Plagakis 2011

All rights reserved. No part of this book may be used
or reproduced in any manner without
written permission of the author

ISBN: 978-1-257-63083-7

Jim Plagakis, R.Ph.
For more than twenty years Jim Plagakis has been the author of the popular Drug Topics magazine column “JP at Large”. He has been a prescient observer of the drug store industry and his predictions have been consistently accurate. Jim loves pharmacy and he knows that it is the job that can present problems. The profession is just fine.

He has recently published “The Prisoners of Comfort” (Lulu.com). It is a study of the unfortunate state of institutionalization that is prevalent in the job of working at a retail pharmacy.

Pharmacists are well-educated and highly-trained medical professionals, but, in the retail setting, the job of pharmacy is regularly relegated to monitoring The Prescription Mill. This is not practicing pharmacy. It will be independent professional acts that will define what our profession is in the 21st Century. Every independent activity (counseling, primarily) is a profound revolutionary event.

In The Rebels of Comfort, Mister Plagakis presents the difficult situation we find ourselves in, the reasons why pharmacists feel so helpless and what we need to do to get professional pharmacy back in the hands of pharmacists.

PriceWorld Pharmacy
Where cost is king
Prescriptions in 15 minutes, guaranteed
When I refer to the company in this book, I will be talking about the mythical PriceWorld Pharmacy. PriceWorld embodies every evil in our industry that I can think of. The $4.00 Prescription. Free antibiotics and free diabetes medication. The infamous timers that some companies use to motivate pharmacists to work faster. The Drive-Through that relegates the pharmacist to a worker in a certain kind of fast food category. Hair-brain schemes to promote the prescription business such as a guarantee that prescriptions will be delivered in less than 15 minutes.
The executives of the company are exclusively non-pharmacists. The CEO is a transplant from a big box store where he had considerable success selling general merchandise, electronics and food and beverages. This CEO had no drug store experience. The executives of the company are non-pharmacists and the middle-managers are all non-pharmacists with MBA degrees. The pharmacists at PriceWorld can be found in the stores or, one level up, as District Managers. The District Managers are supervised by the MBAs.

It was the MBA middle-managers who came up with the ideas of the $4.00 prescription and the guarantee that prescriptions will be ready in 15 minutes or a $5.00 gift card will be handed out. When pharmacists complained, the Pharmacist District Managers acted like the Capos in the concentration camps. They came down with heavy hands to squelch any rebellion because they were afraid of the MBAs. In the end, these unprofessional schemes strip away the patient’s perception that a valuable professional service has been rendered. We become cheap.

The model for PriceWorld is hierarchical. There is one person at the top of the pyramid and that person is the CEO, the ruler or the dictator. At PriceWorld, the CEO is a martinet. He expects the MBAs, the District Managers and the store-level pharmacists to do exactly as they are told. This is not a model that is sustainable for professional behavior. Pharmacists have the right and responsibility to make decisions based on professional discretion. This is not being done at any of the 6,000 PriceWorld stores. Pharmacists fear that they will be punished for behaving in a manner that pharmacists should behave.

The company is well known for cutting corners in the pharmacy. It paid a multi-million dollar fine for snubbing its nose at the federal government and neglecting to do the proper record-keeping for pseudoephedrine sales. The PBM business it runs has engaged in restriction of trade and has violated antitrust laws. If you Google the company, you will find page after page of legal difficulties.

I trust that most of the readers of this book will be pharmacists so I will leave it at that. You know exactly what I am talking about. You could easily add a few paragraphs to the characterization of the company.

The Pharmacist’s Role
The role of the pharmacist has transformed during the past six decades and we have not come out ahead. Look at the result, the reality of our situation in the second decade of the 21st Century. The pictures of pharmacists that are presented of us by the APhA predominantly are laughable. The clinician who spends the day doing MTM for a livable wage is one of the fairy tales that comes out of the American Institute of Pharmacy Building in Washington, DC. Those of you who have followed me know that I am one of the legion of veteran pharmacists who have little respect for the APhA. They do not deserve to be able to call the organization the American Pharmacists Association because they do nothing to advocate for pharmacists. It is almost as if there is a conspiracy to ruin the profession.

The reality is that most of us do not practice pharmacy at all. We bean-count for the company. We tend to the “Prescription Mill”. We don’t even fill prescriptions anymore. We make sure that they have been filled correctly. Filling prescriptions is no longer a professional task. Well-trained technicians can easily fill prescriptions from the intake to the final product with no pharmacist involved..
Sixty years ago, soon after the Durham-Humphrey Amendment of 1951 changed pharmacy forever, pharmacists had two distinct professional tasks. We filled prescriptions for Pharma-made standardized strengths and dosage forms and we compounded prescriptions.
It took decades before we realized that filling a prescription for thirty tablets or capsules is not a professional task that requires a pharmacist for every single step. Recently we have realized that a pharmacist is not needed at all until the final step and perhaps not even then. Advanced technicians will be the prescription-fillers sooner than later. Advanced Technicians will check the work of other Advanced Technicians. Filling prescriptions is no longer a professional task that only a pharmacist can do. There are those who argue that filling prescriptions is no longer a professional task at all.

Durham-Humphrey created Big Pharma. Standardized strengths and dosage forms made the pharmaceutical industry. Until recently, compounding has neglected by pharmacists. It is making a comeback because there is perceived value in non-standardized strengths and dosage forms. Compounding is the quintessential art of the pharmacist. No one else is trained to do it.

I am reminded of a story told by a compounding pharmacist in California. The patient presented the prescription and asked how much it would cost. The pharmacist reported that this prescription could be ready the following day and that it would cost $75.00. The patient complained and said that the doctor said that it would cost $20.00. The pharmacist handed back the prescription and told the patient, “Have your doctor mix it then.”
Pharmacists who compound must be well paid for their efforts. They have specialized talents that are worth a lot of money. Only pharmacists have been trained in the art of compounding. Don’t give it away.

The chain drug store pharmacist wears two hats. One is a distinctly professional hat and the other is arguably a non-professional hat. For those of you who hang your hat on running the “Prescription Mill”, you are basically just bean-counting. I have watched pharmacists pay practically no attention to what they are doing. They tap the keys with barely a look at the screen. When the computer displays potential problems, they give only perfunctory attention. Running the “Prescription Mill” is not a professional task.
Counseling is a professional task. It is what will define us as a profession for the 21st Century. There are important points about counseling.
Counseling is a legal requirement and if you do not counsel, you are almost hopelessly institutionalized. You say that you do not have enough time, that the demands of the “Prescription Mill” are so heavy that you cannot take the time to be a pharmacist. You are short-sighted. What more security could you want? The MBAs at the company would be idiots if they told you not to counsel. Counseling is your responsibility and your right as a pharmacist.

I will repeat the advice that I have given loudly and often. Document, document, document. Write down dates, times and who said what. I can’t imagine that the pharmacist District Managers for the company have a kamikaze death wish. They know that their ass is grass if they dare tell you to break the law.

Professionals do not bean-count. It does not take a Doctor’s degree to run the Prescription Mill. Don’t blame me. I didn’t make it that way. I am just the messenger. A professional is a practitioner who uses discretion and makes independent decisions for the benefit of the patient. Your counseling and my counseling will differ on most drugs. However, neither of us is right or wrong. Both of us behave independently by acting for the benefit of the patient.

The key word is independent. The company can’t tell you how to counsel. That would be idiocy. The company can’t publish a big book outlining how to counsel on every single drug and every single combination of drugs and conditions. The company can’t tell you how to counsel a middle-age man who you suspect of being an alcoholic on the use of temazepam. Or how to counsel a pregnant woman on the use of metronidazole for vaginal trich after she tells you that her husband sleeps around.

We spend most of our time at the company’s stores working for the company at the Prescription Mill. When we counsel, however, we perform an independent action and that is a profoundly revolutionary act. When you counsel, you no longer work for the company. They pay you for practicing pharmacy at their location. They pay you for doing only what you can do, at their location. They can’t tell you how to do it. The company should be very pleased that you are as accomplished as you are because they look very good when you are very good.

Bean-Counting and running the Prescription Mill are not very satisfying, but they take up so much of your time. It is no wonder that you are so miserable at your job. You are wired and using million-dollar technology, so why doesn’t it make you feel any better than five, ten, fifteen, twenty? Counting pills and licking and sticking labels? You spend 90% of your time caught on this hamster wheel. Pharmacists have been whining about the job for thirty years. Is it any wonder?
Counseling is 100% an independent professional activity. As Forrest Gump would say, “Professional is as Professional does.”
I want to be fair. Very few of us can have a 90% Counseling practice and 10% Prescription Mill job because we have not evolved to that yet. Pharmacy is in transition. The company has to survive or we would not have a place with thousands of dollars of space and equipment where we can work and practice pharmacy for a very nice wage. We have to do what is needed and wanted to keep ourselves in a good situation.
That being said, you must practice your profession by counseling or they might try to take the opportunity right away from you. You have no choice if you think you will still be able to pull down $10,000 a month and more in the future. Would you pay that much for an employee who only did the work that a well trained Advanced Technician can do for $20.00 an hour? Hell no! The company has been studying what you do. They would love to pay you less.
There is a law in every single state that every one of us must be willing to go to the barricades to see to it that this law remains in the books forever. We must be willing to temporarily sacrifice our time, our money, even our well-being to protect us from forces that are hell bent on eliminating our profession eventually. We must be willing to get dirty and bruised and bloody if any force tries to change this law. We must aggressively enlist the public for their support. Look out in Arizona.
The law that I am speaking of is this: There must be a pharmacist present when a prescription is dispensed to the patient.
The law makes sense. Counseling needs to take place. The patient may have questions. The Boards of Pharmacy are mandated to regulate our profession for the benefit of the public. It is a no-brainer that the health and welfare of the public could be endangered if they eliminated this law. Look out. The boards have not shown consistently that they are good thinkers.
The company doesn’t care about the patient no matter what they say. The MBAs could not care less if Maggie Jones dies because she was not properly counseled. The company would love to fill the prescriptions in a remote location and deliver them to a dispensary store and have the prescriptions sold by a clerk. You can help prevent this nonsense by showing your value as a professional. Trust me! You get no professional points for running “The Prescription Mill”.

The Pages up above are all video for awhile

Counseling On The Clock

Join the Revolution

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“The Rebels of Comfort”

By: Jim Plagakis, R.Ph.

Send me an email to jaypeegakis@gmail.com and I’ll send you a 11 page preview pdf.

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Also, three books in one volume, 20% less than buying them separately.

“The Prisoners of Comfort”

“The Rebels of Comfort”

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Piss on the cheaters

The CVS culture is cheating. How long can they get away with it? They mess with the FEDS too much.  CVS will get nailed big time if they continue and their new CEO embodies cheating.  He sold enough of his CVS stock right before his promotion to take a profit of $2+ million.  If you practice at a CVS, start documenting.  You could be the next pharmacist millionaire.  Jay Pee

          A CVS pharmacist in St. Paul who blew the whistle on the drugstore chain for overbilling on Medicaid prescriptions will get $2.6 million in a settlement.

The retail pharmacy division of CVS Caremark Corp. agreed last week to pay $17.5 million to settle allegations that it routinely overbilled the government’s Medicaid prescription programs in 10 states, including Minnesota. CVS was allegedly inflating claims for the prescription co-pays that Medicaid picks up for those patients who are primarily covered by private health insurance.

          Whistleblower Stephani LeFlore, who started as an overnight pharmacist in 2008, alerted authorities to the alleged overbilling after noticing billing discrepancies in CVS’ customized pharmacy computer system. She called the private health insurers covering the prescriptions to determine the actual copay Medicaid patients were supposed to pay. In one example, CVS submitted a claim for $26.75 for a co-pay that was supposed to be $25.

          The company, based in Woonsocket, R.I., said in a statement that it didn’t intentionally overcharge any state Medicaid program. It also noted that the group of patients at issue, who qualify for both Medicaid and third-party insurance, make up a small percentage of the overall Medicaid population.

The case was filed in 2008 under the federal False Claims Act and sealed. It was unsealed Friday when the settlement was reached.

          Court documents describe LeFlore as an experienced pharmacy manager, a graduate of the University of Minnesota’s pharmacy college who worked as an overnight pharmacist for CVS in St. Paul. She could not be reached for comment.

One of her four lawyers, Bob Christensen in Minneapolis, called the $17.5 million “a significant amount of money recovered for the taxpayers.”

          “This person took a risk to bring this to the attention of the government,” he said. CVS will pay the federal government $7.9 million plus interest, and the states $9.5 million plus interest. The states include Alabama, California, Florida, Indiana, Massachusetts, Michigan, Minnesota, New Hampshire, Nevada and Rhode Island.

The U.S. Department of Justice announced the settlement Friday, saying it is emphasizing combating health care financial fraud.

          “Medicaid covers the poorest, most vulnerable people in American society. Overcharging this needed government program for prescriptions is a disservice to everyone and won’t be tolerated,” said Daniel Levinson, inspector general of the U.S. Department of Health & Human Services, in the statement.

In 2008, CVS agreed to pay $36.7 million to settle charges that it overbilled Medicaid by substituting more expensive capsules of a popular generic antacid instead of the prescribed tablets.

Not my daughter, Mister! I want another pharmacist.

The prescription was for SMZ/TMP DS for UTI. He asked me how many tablets and for how long. He is a dermatologist. I told him that it is best to err on the side of too long rather than too short. I added that 3 or 4 days would probably be enough.

“Let’s go ten days,” he grumbled.

I asked him if he wanted anything else and, with attitude, he asked what I meant by the question.

“There is usually stinging and burning,” I said. “We can handle that with a couple days of phenazopyridine.”
Of course, he wanted to know all about it and I wished that I had saved the idea for the OTC strength. I was thinking of his daughter’s budget. The Rx Only version would be covered by her insurance.

He okayed the prescription and then asked, “Is there a lot of this kind of infection down there?” He said it as if he was referring to Yellow Fever. He made it sound as if he thought UTI was a sub-tropical Galveston thing.

“There is no more UTI here than any other place I have practiced,” I said.

“Well this is the fourth time my daughter has had a UTI in four months,” he complained. “She is a healthy girl. There is something wrong down there.”

“Give her a second prescription,” I advised, “With the directions of ‘Take one tablet after each sexual encounter.’”

There was a very long silence of the lambs. He cleared his throat. I knew what was coming. He could not handle the vision of a studly Galveston boy poised above his Princess. Along with the picture, he probably imagined the sounds and the aromas. Poor guy! And he is a medical doctor in the 21st century.

“Excuse me,” he said, “My daughter is NOT sexually active.”

 “I’m sorry,” I said, “Some of the medical students down here are sexually active. My error.”

“Why do you think that my daughter is having sex down there?”

“I don’t think anything about your daughter. I just met her for the first time and why would she tell me, her pharmacist, that she is having sex.”

“That would be none of your business, mister, if my daughter was sexually active. I don’t want her to have anything to do with your ideas. Let me talk with another pharmacist.”

I told him that he was out of luck. “Doctor, I’m the only pharmacist here right now.” I let the silence linger. He was the aggressive side of the conversation. It was his serve.

“All right,” he said, “Her mother and I may have been too protective of her. Just the idea of her having sex with a stranger makes me sick.”

“He wouldn’t be a stranger to her,” I said.

“Have you met him?” His voice was pitched too high.

“No. She was with a female, another student.”

“Are they promiscuous down there?”

I didn’t like the DOWN THERE, like Galveston was a sex farm in Brazil. “Doctor,” I said and my voice was firm. “This is no different from Chicago or Cambridge. Twenty-something students are likely to be sexually active. This is 2009, not 1959. If your daughter isn’t taking oral contraceptives, she should be.”

“Why do you say that?”

“Because she might not be getting recurrent UTIs if she was using condoms.”

To make a painful story shorter, I will skip the drawn out education of a closed-minded father and just say that I suggested he turn this part of his daughter’s medical care over to her gynecologist.

“I don’t think she has a gynecologist.”

“She is 24 years old,” I said, “Ask your wife. Trust me. She has a gynecologist.”

Two hours later, I get a call from New Hampshire. It was the girl’s gynecologist. I did not like her unprofessional sharing of a good laugh at the dermatologist’s expense, but perhaps that is how they do it in New Hampshire. I found out that the girl had been taking an OC since she was a senior in high school. She gave me a new Rx for Yaz and an Rx for Nitrofurantoin. Enough capsules for a 5 day course for this infection and additional capsules for one capsule immediately after each toss in the rack, 30 of them.

Who said, ‘Father knows best’?

The Dispensing Lab at DRTB University School of Pharmacy, Equipment donated by PriceWorld Drug Stores

I wrote this a few minutes ago and I wondered about what you think:

How will the revolution proceed?  I can tell you where it will not come from.  You won’t find it in the alphabet soup.  It won’t be the APhA, NACDS or NCPA.  Heaven help you if you thing that the NABP will start anything.

            It will not come from the universities. The schools of pharmacy are engines for running the status quo.  I agree that it shouldn’t be that way.  That is counterintuitive because academia is supposed to be the breeding ground of innovation and new thinking.  The schools could take the role in creating the space for a quantum leap in the job of working as a pharmacist, but don’t count on it.  The colleges of pharmacy gorge themselves on corporate money.  The private interests of the schools are more important than the interests of the profession.  We are all adults.  We know that when you take money, you are beholding to the donor. 

          The schools have laboratories paid for by the drug store chains.  Wal-Mart pays for the pharmacy computer systems in some of the schools.  Take a tour of the schools and you’ll find corporate brands everywhere.  Do I expect it to change?  Hell no!  Does it have to change to allow for a sea change in our jobs.  No! 

This is NOT the Prescription Mill

Today, I was asked if I wanted to be “trained” to provide MTM.  Of course, I said “YES” loudly.  The more patient contact the better.  Then, I was told that I will be paid. Probably a token amount, but it opens the door.  I thought you would want to know, Eric.

You come to Rite-Aid and you get real pharmacy. Fast and cheap.

 I heard today that CVS may try this. Anyone else

hear this? 4/7/11

If you get Consumer Reports, the May issue features a section on “Best Drugstores.” I was stunned to read that a primary determinant in rating community pharmacies was how fast you can get your prescription filled. While Consumer Reports actually called this factor “speed and accuracy,” it was defined as, “the factor most closely tied to satisfaction” and “reflects how long readers had to wait for service at the pharmacy counter and whether their medications were ready when promised.” There was no actual rating for accuracy, which, in fairness, would have required a scientific study, which was beyond the scope of the report. What a disservice Consumer Reports has committed when it comes to consumer safety!

There’s no question that speed is a desirable quality among consumers when choosing a pharmacy. The pharmacy chains cleverly use this knowledge to market their stores. For example, you may have seen a recent Rite Aid Pharmacy TV advertisement that promises customers a “15-Minute Prescription Guarantee” to dispense up to three new prescriptions within 15 minutes or less. If the pharmacy fails to meet the mark, the customer receives a $5 pharmacy gift card.

I don’t want to single out Rite Aid because we’ve seen similar campaigns by other pharmacy chains, with gifts ranging from cash coupons to free movie rentals, meals, and so on. One CVS billboard read, “Get in/Get out”—with nothing else except the CVS Pharmacy logo. If you read the fine print, the Rite Aid ad mentions that “prescriptions requiring ordering, prescriber contact, third party assistance, professional services, or prescriptions presented immediately before or during a Pharmacist lunch break” don’t count. Still, the message from pharmacy chains is clear. It’s all about speed. I get it; you don’t want to wait.

But please keep this in mind: speed reduces safety. You may recall, about 20 years ago Domino’s Pizza guaranteed that customers would receive their pizzas within 30 minutes of placing an order, or they would be free. The company later settled lawsuits brought by the family of a woman who’d been killed by a speeding Domino’s delivery driver and another suit brought by a woman who was injured when a speeding Domino’s delivery driver ran a red light and collided with her vehicle. The 30-minute guarantee was soon dropped.

Again and again, here at the Institute, we hear from consumers who tell us of medication errors that harmed them or a family member. What is a chief cause? Rushed pharmacists unable to take the time to thoroughly check their work. Here’s just one example of typical of reports we receive:

“Prescription volume was high. The pharmacist was rushed and constantly interrupted while filling my prescription. The wrong strength tablet (50 mcg) of the right drug (Levoxyl) was dispensed to me in a retail pharmacy (chain) setting. The correct strength was 75 mcg.

Sadly, we also hear from families or their advocates after fatal medication errors. I always wonder if the pharmacist who dispensed the wrong medication felt rushed and/or pressured to fill prescriptions within unrealistic timeframes that can lead to cutting corners and inevitably, medication errors.

If you talk to pharmacists themselves, they’ll tell you how much they hate 15-minute (or 10-minute, 19-minute, or any preset timeframe) “promise programs.” They hate being rushed and feeling forced to cut corners to meet their company’s unrealistic promise. Do a Google search on pharmacists and 15-minute promises, and you will see some of the chatter about it. They feel it jeopardizes public health by discouraging them from spending enough time to:

1) check the patient’s history and other medications that have been prescribed

2) verify that the prescribed dose and the directions for use are safe for the patient

3) check that the patient is not allergic to the prescribed drug

4) check to make sure the new prescription medication is safe to take with previously prescribed medications

5) make sure the patient has not been prescribed more than one medicine that serves the same purpose

6) call the prescribing physician’s office to discuss a safety concern or clarify a barely legible or incomplete prescription

7) thoroughly double check the medication and label after the prescription has been filled to be sure it is correct

8) educate the patient about the proper use of medications when picking up filled prescriptions

9) perform any other critical task that promotes safety.

Today’s prescriptions medications are much more sophisticated than those used a decade ago. Thus, a simple mistake could lead to serious harm. Given enough time to critically think about each prescription and employ high-tech computer software, your pharmacist can capture a mistake that your doctor has made when prescribing the medication and avoid making a mistake when filling the prescription. But a rushed pharmacist may never have a chance to do more than quickly find the drug on the pharmacy shelf, count out the number of doses to fill your prescription, print out a label and place it on the bottle, and put the bottle in a bag for pick-up. These rote tasks may take only 15 minutes or less to carry out, but working at this speed clearly leaves no room for the pharmacist to ensure accuracy.

You can contribute to your own safety by allowing your pharmacist the time necessary to complete each of the functions mentioned above—without distractions. Whenever possible, drop your prescriptions off in the morning and pick them up later in the day. Or, call the pharmacy a day ahead of time for refills. Use interactive telephone systems for renewals. Making sure your medicines are safe and effective takes time.

You can learn a lot more about what goes on behind the pharmacy counter in pharmacies that want you to make safety, not speed, the primary determinant when making a choice in where you have your prescriptions dispensed. I highly recommend clicking on the link above to read an article on this topic.

As an organization, the Institute will also be pursuing the state licensing boards of pharmacy to help limit unrealistic promises to consumers to fill prescriptions within timeframes too short to ensure safety.

For more on Institute for Safe Medication Pracrtices consumer website, go www.consumermedsafety.org.

 From Rite-Aid’s website.

Let us fill your prescription in 15 minutes. Guaranteed.

Bring your prescriptions in to Rite Aid today and we’ll fill them in 15 minutes guaranteed – or you get a $5 Rite Aid Gift Card.*

After all, we care about your health and wellness. Helping you achieve your goals is what we’re all about.

We also care about your time. Just bring your prescriptions in today and you can get well – Sooner.

* Not available in NY. Guarantee applies to prescriptions dropped off in-store and at drive-through only. Offer is limited to one gift card per order of 3 prescriptions maximum. Certain exclusions apply including services, or prescriptions requiring ordering, prescriber contact, third party assistance, professional services, or prescriptions presented immediately before or during Pharmacist lunch break.

"Relax, Sid. They whine, but they are sheep. Make it ten minutes. Hardy Har Har".