Peter A. Kreckel, RPh

We all know that that Friday afternoons are hectic in the community pharmacy, especially the first of the month. One Friday, after finishing my typical lunch (yes, I take 10 minutes to do that), I called a pharmacy for a transfer for one of our patients. As I was on the phone, I overheard my technicians, Amber and Katie, looking for trifluridine eye drops. I reminded them to check the refrigerator. None there. After I was done with my call, I asked who wanted the trifluridine drops, assuming it was another Thompson Pharmacy. They said it was some eye doctor’s office but could not recall which.

About 7 years ago, my niece Rachel Fritz, who is now an optometrist, stayed at our home while interning at a local eye clinic. I came home after work one day and told her that a Medicaid managed care organization (MCO) denied a claim for trifluridine because the patient used their 6 prescriptions for that month. I called the ophthalmologist and got the medication changed to valacyclovir, knowing Medicaid would pay to treat genital herpes but not herpes keratitis.

“Uncle Pete, herpes keratitis is sight threatening, and you probably saved that patient’s vision,” Rachel said. Herpes keratitis needs to be treated within hours of diagnosis, and waiting 2 days for prior authorization is not appropriate. My techs called all the ophthalmology practices in Altoona, Pennsylvania, and tracked down the nurse who made the request.

I spoke with her, and she said no one in the city had the eye drops in stock. I told the nurse to give me the prescription over the phone and my driver would go to the warehouse to pick up this sight-saving eye drop. I called “Rich,” the representative at Value Drug, around 1:15 PM, and he set the wheels in motion. Less than 2 hours later, my driver, Don, appeared, drops in hand.

When the patient’s daughter came in at that day, she was most appreciative of our efforts. Her 90-year-old mother was a customer of a big-box store, where little effort was made to help this patient. The woman handed me her mother’s Medicare Part D card, and Amber ran the prescription through our pharmacy filling software. When Amber got the approval, her bright smile was absent from her face as she called me over.

Amber informed me that Medicare Part D had paid us $123.02 for this sight-saving eye drop that cost us $189.93, for a loss of $66.91. That’s not counting all the time my techs spent, the mileage and time my driver spent, and time I invested to help this 90-year-old woman get the medication because the big box had no interest in doing so. What should we do? I assured Amber that over the weekend, I would fill out the paperwork to challenge this gross injustice of payment.

My only wish is that the pharmacy team at this MCO could hear my niece say that herpes keratitis is sight threatening and needs to be treated immediately. There was no time to scour other warehouses to find a cheaper generic. This small, 1200-square-foot drugstore will take care of the patients and their problems that the big-box guys could care less about.

Clare Boothe Luce is attributed with saying “No good deed goes unpunished.” This independent pharmacist hopes that this is not the case for the herculean efforts made to help this most needy patient.

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This small, 1200-square-foot drugstore will take care of the patients and their problems that the big-box guys could care less about.

No Good Deed Goes Unpunished

Although the quote “take the time to walk a mile in his moccasins” is often attributed to the Native American culture, it in fact comes from a poem written by Mary T. Lathrap in 1895, originally titled Judge Softly. I feel we can adapt this to our profession: “take the time to work a shift in his/her lab coat.” 

I joined my son-in law Mark for a conference in Las Vegas, where he gave three presentations for PAIN WEEK. One evening we attended a show, and we were seated next to a patron who told us she worked in marketing. She named the pharmacy chain, one of the bigger ones. 

She said her focus on marketing is the “store experience.” She described how they fit people with contact lens and glasses and send them into the store and track their eye movements. Amazingly, most eyes seemed to focus on finding a trash can! She described how they focus on signage, color, music, lighting, shelf placement, and anything that could improve the “store experience.”

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She also described how a bunch of her colleagues are traveling to London to witness how British pharmacies operate. When they get back to the U.S., they are going to implement ideas gained from watching their British counterparts in this chain’s “wellness centers.” 

Finally, the independent pharmacist couldn’t resist, I asked: "Did you ever spend a day in one of your pharmacies to see why your pharmacists are so unhappy? Did you ever see the overworked pharmacist, technicians, and cashiers answering phones, staring at computer screens, and trying to accomplish all 10 plus metrics.” I have a few colleagues that work for said chain, and they are the most unhappy healthcare professionals anywhere. I advised her to come to my pharmacy when I’m staffing, and then head down the street to their chain and see the difference.

Imagine one of the biggest drug chains spending millions of dollars, when this community pharmacist knows the obvious. I call their store for a prescription transfer, and it takes at least six minutes for a pharmacist to get to the phone. Through the wizardry of electronics and social media, I can save this chain a bundle of money so they can use that money to get more staffing. 

First off, their CEO makes almost 23 million dollars a year. That equals 184 pharmacists’ salaries. For my pharmacist colleagues, the 23 million could hire an almost 1000 technicians, full time at $12.00 per hour. Secondly, let’s cancel your marketing staff’s trip to London. I can tell you what works to increase customer satisfaction. Third, start paying attention to your store staff, if they are too afraid to speak up, don’t be surprised. 

I told this member of your marketing team “the only reason most people go to your chain is because they are forced by your PBM.” Your chain’s pharmacists work extremely hard and get less technician hours every year. They are told to do more with less. Cancel your marketing trip to London, and come to Altoona, PA, where this 61-year-old passionate pharmacist is more than willing to help rescue the 12,000 plus careers of your pharmacists. Not that Altoona PA is an expensive place to stay, you can save even more money by staying at our house. I can accommodate four of you in one of our three empty bedrooms!

Give me a call, I can assure you the phone will be answered within 4 rings! Show up in your white lab coat and sturdy shoes, and you’ll learn so much more than you would taking a trip to London.

From Pete Kreckel, why chain pharmacists have answers that chains are looking for.

Opinion: What Chain Pharmacies Can Learn from Independents

On July 15, my daughter Gretchen Garofoli appeared before the Senate Subcommittee to discuss financial barriers to adult immunizations. The night before she headed to Washington DC, I said “nothing to worry about GG, but please while you’re there get me an appointment to the FDA. I’ll have them straightened out in a couple of months before I get fired!” 

Many of us in healthcare feel that the Food and Drug Administration (FDA) are in the back pockets of the drug companies. It seems that the FDA are always catering to the desires of the pharmaceutical manufacturers. In a 

, I implored the FDA to standardize the appearance of all generic drugs. This would show beyond a doubt that the FDA is concerned about patient safety. No one ever contacted me. Hey, I’m just a community pharmacist whose major concern is always the safety of his patients. Heck, old Kreckel doesn’t even have a political action committee!

Back in October 2013, my niece Rachel Fritz was staying at our home when she was doing an optometry rotation in State College. I presented an online lecture on optometry at the college. After I completed my lecture, she asked “Uncle Pete, why didn’t you tell them about the cap colors on ophthalmic products?” Rachel explained that the anticholinergics had red caps, prostanoids had teal caps, anti-inflammatories had grey caps, antibiotics had brown caps, et cetra. In over 30 years of community practice, I never had this explained to me. I’ve yet to meet a pharmacist who ever had this covered in pharmacy school. The American College of Optometry pushed the FDA for this, they even 

 to minimize variations on the color green! 

Last week, at the doctor’s clinic I work at, once again there was great confusion regarding the asthma/COPD inhalers. I’ve complained about this for years that there is no standardization of asthma inhalers with respect to appearance. We’ve heard horror stories of people using steroid inhalers for emergency, and no one steps up to push standardization. 

My niece, now Dr. Fritz, says that optometrists use these color codes to talk with patients. “Use the yellow cap (Timolol) twice daily, and your teal color cap (Xalatan) at bedtime.” She says during post-refractive surgery, it is less complicated when instructing patients when to use the red, gray, and brown cap colors.

I’d like to see the FDA take the initiative to resolve this issue. I’ve heard some of the sales reps say they would have to retool their equipment to change these colors. Fifteen years ago, we were selling generic albuterol inhalers for $8.00 each, and the FDA had the manufacturers change the valves to accommodate CFC-free formulations, to minimize chlorofluorocarbons that were allegedly damaging the ozone layer. Albuterol inhalers all cost over $50 now. Most of the other inhalers for asthma or COPD cost over $300. Certainly, the lives of my asthma and COPD patients deserve as much attention as the ozone layer.

"I’ve yet to meet a pharmacist who ever had this covered in pharmacy school," writes Kreckel. 

Opinion: Color Coded Inhalers

Dr. Martin Luther King once said, “We must learn to live together as brothers or perish together as fools.” We know he was referring to society as a whole, but this could easily be extended to the profession of pharmacy.

I’m not much of a philosopher, so I prefer to compare our profession to a cable TV show, Storage Wars. This wildly popular show depicts owners of second-hand shops bidding on storage lockers that they briefly glimpse before the auctioneer starts the bidding. 

The drama of this show is not so much the bidders getting the best deal possible, but rather in “putting the screws” to each other. The bidders do not take pride in finding value for their businesses, but in making the other guy pay! With everyone trying to ruin the other person’s business, the only winner is the auctioneer.

I watch this program and compare it to our profession. I see Dave Hester, the “bad guy” who frequently bids up the locker, as the large pharmacy chains. They’ve got the money to make bad business decisions and have enough assets to survive the bumps and bruises of those decisions. Like Dave, their goal isn’t so much in ensuring the viability of their business, as driving the others out. 

EPA Final Rule: What Community Pharmacists Need to Know

One of my biggest disappointments in our profession is the role of the pharmacist embedded in the PBM or health plan system. I get frustrated to no end when I see my fellow pharmacists working behind the scenes to make the jobs of their colleagues in community practice almost unbearable. Sad to say, I have precepted some of these pharmacists as students. I have seen these pharmacists set up parameters for insulin dispensing that force pharmacists into violating the law, such as opening packages of insulin pens to fulfill the day supply cap set by the managed care organizations.

One local health plan recently changed SGLT2 inhibitors. Only one SGLT2 inhibitor has been proven to prevent death. It was removed from the formulary and replaced with an SGLT2 inhibitor that has no proven cardiovascular benefits. They also removed the only DPP4 inhibitor that does not require renal dosing and replaced it with a DPP4 inhibitor that has three different strengths because of renal dosing. These pharmacy departments took the best drug in each class and replaced it with the worst drug in each class. Their brothers and sisters in community pharmacy must call the physicians’ offices to make changes for these inferior drugs. 

I teach my pharmacy students to learn the drug class, indication, mechanism of action, and side effects. Then I tell them to learn the salient differences between these drugs in that class, such as the benefits and dosing parameters. That is what separates us pharmacists from the other healthcare professionals. This subset of pharmacists who work for these managed care organizations has failed the profession and themselves miserably. 

The decisions these health plan pharmacists are making are based only on financial criteria. You don’t need a pharmacist to do that; accountants are more skilled at it.

I have a word of caution from this very experienced pharmacist to these health plan pharmacists. Your day is coming when a novice accountant will be sitting in your position simply because you have demonstrated a total disregard for pharmacokinetics and therapeutics. 

When we see the recent shenanigans with Walmart, laying off pharmacists and replacing them with younger (and cheaper) pharmacists, we need to be shouting from the rooftops. We need to stand up for our brother and sister pharmacists in hospitals, community practices, clinical practice, and anywhere our profession has such a profound impact on healthcare. 

Remember the words of Dr. King: live together or perish together as fools. Picture Dave Hester from Storage Wars in a white lab coat.

We need to stand up for anywhere our profession has a profound impact on healthcare, writes Kreckel. 

Author | Peter A. Kreckel, RPh

Articles

No Good Deed Goes Unpunished

Opinion: What Chain Pharmacies Can Learn from Independents

Opinion: Color Coded Inhalers

Opinion: Perish Together as Fools?