Friday, March 11, 2005


My brush with the health care system, part II: A trip to the pharmacy

As I said in my last post, getting the prescription on the basis of, essentially, a self-diagnosis, was a very new experience for me that struck me as cutting edge health care. But the pharmacy where my prescription was called in was very old fashioned. It's a small family-run independent pharmacy, right in my neighborhood. The medications are kept in a sort of demi-wall of lengthwise wooden drawers, each marked with the first few letters of some medication, in alphabetical sequence. It was so damn cute, I could hardly stand it – I determined on the spot to get all my prescriptions filled there from now on.

They had the prescription, but hadn't filled it when I walked up to the pharmacy counter, so I saw them do it. Well, sort of. Like any pharmacy, they work behind a desk with a privacy screen so you can't actually see them put the pills in the bottle. At this pharmacy, I was able to see them pull out the drawer with my drug, which is more than you see at most pharmacies, where the whole process is hidden by privacy screens or partitions.

The tradition of hiding the pharmacy process is kind of strange when you think about it. Most of us probably know what the process looks like, having seen it in stock footage on local news broadcasts. They take the pills out of a large container and put them in a small one, sticking a label on it with your name, the drug's name, dosage, etc. It's not like they grind up the powders themselves back there with a mortar and pestle and roll pills the way they did 100 years ago. What is it exactly we're not supposed to see? Will the medicine seem ineffectual to us if we knew that the prescription was not specially made to order for us by a team of trained scientists and delivered by diplomatic courier direct to the pharmacy? Will we think it's candy, or a placebo, just because it looks like it comes from a candy or bulk food bin?

I realize that open kitchens in restaurants are more the exception than the rule, but that just encourages bad practices, doesn't it? What are those pharmacists doing back their – spitting into our drugs? (Or worse... you Fight Club fans know what I mean, don't you?)

Anyway, I could tell that they had the pill bottle filled in about two minutes. But for some reason, I waited and waited. The pharmacist and his assistant asked for my prescription drug card, hovered over a computer, typed, swore, asked for my prescription drug card again, typed some more, laughed. Several more minutes went by. Then I heard a computer printer – an old one. Perhaps a dot matrix printer. (Can you still get ink for those?) It printed. And printed. I think I waited 15 to 20 minutes in all, so the time for getting my prescription filled consisted of 10-15% pharmacology (transferring the proper number of pills from the candy bin to the pill bottle and labelling the pill bottle) and 85-90% health care bureaucracy.

What was the document they gave from that interminable print job? Why, the HIPPA privacy notice, of course.


The mystery behind the interminable wait you experienced is actually the subject of several health care fraud investigations. Here's what's happening:

Your HMO contracts with a Pharmacy Benefits Manager (PBM). The theory behind PBMs is that they reduce the HMO's drug costs by aggregrating purchasing clout to become the ultimate prudent buyer and negotiate lower drug prices with the pharmaceutical manufacturers.

It took the manufacturers about five minutes to take over the system. First, Merck simpy purchased one of the largest PBMs, Medco. (Later, after both had been sued by DOJ for defrauding Medicaid, Medicare, and government employee HMOs, Medco was sold at a huge loss.) Other manufacturers which thought buying a PBM was too obvious simply rented them. The drug companies give undisclosed rebates to the PBMs based on how much market share gets moved to the rebate-issuing manufacturer and away from competitors.

Now PBMs are about as subtle as the U.S. military in Iraq. You probably experienced one of their ham-fisted approaches. When your cute, antiquated pharmacists punched your HMO information and the drug information into the computer to get billing and copay amounts, a program written by your HMO's PBM interrupted the cyber-festivities and temporarily froze the transaction.

This usually happens as a way of pressuring the pharmacist to switch you to a drug different from the one your doctor prescribed. The delay is intended to pressure your pharmacist into either covertly and illegally switching you to the PBM's preferred drug, or at the very least forcing the pharmacist to call your physician and ask her to switch you to a different drug.

It could be a software glitch. Or it could even be benign. PBMs claim that their software checks for harmful drug interactions, depending on what other drugs you are being prescribed. They also claim that their software can identify drugs which are even more effective, or are equally effective and less costly. More likely, the alternative drug is simply less costly to the PBM, with no savings to the HMO, and certainly no savings to you.

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