There’s been a lot of talk locally about the methamphetamine problems in Oklahoma, and the desire to further restrict pseudoephedrine (PSE) sales in an effort to decrease or eliminate the meth problem altogether. One gentleman has gone on a personal quest to restrict these sales, travelling from town to town attempting to convince city leaders to pass city ordinances requiring PSE be sold only by prescription. While I commend this gentleman in his efforts, there are some ‘unintended consequences’ that these restrictions will cause.

As background, the current law requires that PSE only be sold through a pharmacy, only by a licensed technician or pharmacist. The pharmacist or tech must get the state-issued identification of the purchaser and input this information into a statewide database. The database tracks whether the person has purchased too much PSE. Purchases, as well as attempts to purchase, are immediately registered. State law restricts these purchases to 3 grams of PSE in a rolling 24-hour period (100 - 30mg tablets), or 9 grams of PSE in a rolling 30 day period (300 - 30mg tablets).

People who purchase PSE for illegitimate reasons attempt to circumvent the aforementioned restrictions by going to pharmacies in groups, with each person purchasing their limit of PSE. It is not unusual to see reports of carloads of people going into a pharmacy and standing in line to purchase PSE, one after another. I have been told stories by law enforcement that these people will take the product to their car and begin the ‘shake and bake’ method of meth production immediately, and have the finished product by the time they get home. Those who don’t immediately manufacture it will take the tablets and sell them to the meth ‘cook’.

The new restrictions being proposed involve moving the purchase of the tablet form of PSE to a prescription-only basis. I’d like to explore some of the consequences of making this change.

1. Supporters of the proposal state that liquid-form PSE, including gel caps, will still be available for purchase without a prescription. This is true, but…..

PSE is not available as a single-ingredient product in a liquid gel cap form. Liquid gel cap products containing PSE also contain other ingredients, such as ibuprofen or acetaminophen (note that every time a television station shows a liquid gel cap form of the product in their stories, it is an Advil product, containing ibuprofen). There are legitimate clinical reasons that a person may not be able to take a product containing ibuprofen or acetaminophen.

PSE is available as a single-ingredient product as a liquid. I’m not sure that people will be happy having to carry around a 4 ounce bottle of syrup to treat their sinus headache, but it is an option.

Some have argued that liquid versions of PSE are less effective or work for a shorter period of time than tablet versions. I know of no clinical basis to support these statements.

2. Some have suggested reformulating the PSE tablets into something that cannot be crushed and used. They suggest modeling a product after Oxycontin – a narcotic pain medication that has been frequently abused by crushing. The Oxycontin tablet has been modified where it cannot be crushed as easily. Providing PSE in a hard-to-crush formulation may slow the abuse, but…

Understand that the active ingredient of Oxycontin has been available generically for years, but Oxycontin itself is not available generically. The reason for this is because it is not the medication that has been patented, but the release mechanism (the tablet).

Just for grins, I checked the cost of a regular release oxycodone tablet with the same strength Oxycontin tablet. The Oxycontin tablet is more expensive by a factor of 13 ½. While I can only speculate on what the eventual cost would be of PSE in an Oxycontin-type tablet, if you used these numbers, a $10 bottle of generic PSE now would cost $135.00 after modifying the tablet.

This also assumes that at least one company will be willing to develop such a crush-proof tablet.

3. Moving PSE to prescription-only status WILL make it more expensive for the end user. The patient will now have to take time away from work (sick time from the employer), have an appointment with a doctor (copay), and fill a prescription at the pharmacy (another copay). The actual cost of the product will also go up, as when a pharmacy fills a prescription, there is a set cost (overhead) involved that is not involved with the sale of an over-the-counter item. Prescription input, labeling, bottle, clinical evaluation against other medications, transmission of the claim to the patient’s insurer – all of these things take time and money. The pharmacy WILL charge you for these things, all of which are currently not required with the purchase of the over-the-counter version.

What might have been a $5 purchase to self-treat a sinus headache becomes a half-day trip to the doctor and pharmacy, with much greater expenses. And this doesn’t even account for those who may be in rural areas with restricted access to healthcare providers as it is.

I have mentioned to some that I am reluctantly supportive of the attempts to move PSE to prescription status. Most have been surprised about my support, knowing my conservative beliefs.

As owner of a pharmacy, I am the ultimate authority as to whether I sell a product to a person. When a carload of PSE users comes in one after another to purchase product, I have the authority and discretion to deny questionable sales. Chain pharmacists may not have the ultimate authority to question or deny sales. It is much simpler for them to make the legal (but questionable) sale than rock the boat and perhaps get into trouble from their superiors.

I suspect if you asked technicians and pharmacists who worked at chain stores, the general company policy for PSE sales would be “if the tracking database says they are able to purchase, then sell it to them”. Pharmacists don’t want to be put in the position of being the enforcer. Many times, I have been handed narcotic prescriptions that have CLEARLY been forged, but the prescription has markings on it that show it as previously being presented to another pharmacy. The pharmacy simply returned the prescription to the patient and told them it was “out of stock” – because the pharmacist didn’t want to mess with it or get involved.

As it stands, the system works IF the pharmacist is allowed the ability to decline a sale even if the tracking database says that the sale is permissible. If the pharmacist is unwilling or unable to exercise that judgment, then unfortunately it is best that the judgment be removed from their hands.

Last night, a local television station (who “works for YOU!”) presented a story about prescription errors.

The Executive Director of the Board of Pharmacy does a nice job of giving stock answers about the ‘causes’ of prescription errors – handwriting, transcription problems – but he doesn’t address the 800-pound gorilla in the room.  And that’s why you have me.

I would venture to bet that the majority of prescription errors made by pharmacists are due to volume. 

Like it or not, a pharmacy has to fill a pretty large volume of prescriptions in order to survive.  Margins have been getting smaller (insurance companies have to make a profit, too), and pharmacies have had to cut back on staffing in order to even maintain their same profit levels.

Fewer staff = more prescriptions per person = more chances for mistakes.

Our buddies at Wal-Mart haven’t helped matters with their $4 program.  Yes, I know that people LOVE the program.  Consider the consequences, though.  How many of those $4 prescriptions does a pharmacist have to fill in order to turn a profit?  Wal-Mart has made it clear that prescriptions are now a commodity at their store (like bread and milk), and that pharmacists are not professionals, but a legally-required part of a fulfillment process – like assembly line workers.  I can assure you – if they could find a way to fill prescriptions without an expensive pharmacist, they would do it.  

So why didn’t the news station point out the obvious?  Because they’re busy promoting the hype of ‘low prices’.  Either they’re not smart enough or unwilling to recognize the connection between the competitive pressures of lowering prices and increases in the possibility of errors.  It's much more exciting for the station to say, "Look, we investigated and saved you money!", than it is to say, "Look, we sent you to an error-prone pharmacy!  Hope you get better soon!"

The chains will point to automation as a factor that decreases errors.  Automation doesn’t solve everything.  There are some software programs that allow prescriptions to be sent electronically directly to the pharmacy’s prescription processing computer.  The majority of prescriptions, though, are either handed to the patient, faxed to the pharmacy, or called to the pharmacy.  As long as you have humans involved in ANY aspect of filling, mistakes can happen.

So how do you decrease the likelihood of an error? 

First, know your pharmacist.  Yeah, I know, I keep harping on this.  Well, think about it.  How can you assess whether the person behind the counter has the aptitude to fill your prescription properly if you’ve never even talked to him?  Yes, I know he has to pass Board exams and get his license from the state.  That’s no guarantee that he can construct a coherent sentence, or hasn’t taken the last 20 years off.  Trust me, there’s some of them out there.

Second, know the pharmacy staff.  If you see different personnel every time you’re in the store, something’s wrong.  Either the work environment stinks or they don’t pay very well.  Either one is a sign that the store management/ownership is cutting corners.  And having fewer, less-experienced personnel is a bad thing for you.

Third, ask questions before you leave the pharmacy.  Know what you’re supposed to be taking and why.  And if the pharmacist is too busy to come out and answer your question, then the pharmacy is not properly staffed.   

Fourth, have patience.  A properly-staffed pharmacy will generally have your prescription ready in 15 minutes or less.  Be aware, though, that if there’s a problem, you’re going to get to wait a little longer.  You should be more worried that the pharmacist gets it RIGHT than whether Billy makes it to his t-ball game on time.

Fifth, if your doctor insists on writing his prescriptions by hand, make sure that YOU can read it before leaving – especially the drug name.  If you can’t read it, we may not be able to, either.

Lastly, trust your gut.  If something sounds wrong, ask again.

As I write this, the kabuki theatre that is our federal legislature in is discussing how to ‘fix’ the healthcare system in the U.S.  There will be much discussion on the uninsured, ‘bending the cost curve’, the ‘doc fix’, excessive insurance profits, and the like. 

As you watch the resultant news reports and promises of ‘solutions’, I ask that you consider this – most of the people you see ‘solving’ these problems have never held a non-government job in their lives.  They have never owned a business, written a paycheck to an employee, or paid a business tax.  They have never actually received a paycheck in an envelope, and taken it to the bank to deposit.  They have no idea how their healthcare is paid for, as they never see the bill for the premium.  They have their own doctor on staff at the Capitol, so they don’t worry about sitting in a waiting room.

If you asked these people to explain the difference between gross profit and net profit, they would stare at you with a dumbfounded look.  If you asked the difference between price and cost, they would give an explanation that would soon fill the air with the aroma of a west-Kansas stockyard.

Unfortunately, that failure to understand the difference between price and cost extends to the layman.  As I explained in my previous blog post, the average American doesn’t understand that price does NOT equal cost.  The SOLE concern of the American public is “what PRICE must I pay?” – or more specifically, “what DIRECT price must I pay?”.

The American public understands a PRICE when they write a check, pay a bill, or fork over cash.  They see a direct price to benefit relationship.  And the higher the price, the more painful the transaction.

They do NOT see the behind-the-scenes cost involved.  When the public pays a $25 copay for a prescription, they don’t see that there is a COST for the pharmacy to file a claim, there is a COST to pay the help, there is a COST for the insurer to manage benefits for the employer, and there is a COST built in as profit (gasp!  A four-letter word!).

To illustrate, let me use an example from Financial Peace University.  In one of his lessons, Dave Ramsey explains that studies have been done to determine the physical effects of paying for an item – how your body reacts to paying for something.  They used 3 forms of payment – cash, debit card, and credit card.  When people paid for an item with a credit card, the ‘pain’ receptors in their brains didn’t activate.  Over the past 50 years, the American public has developed an internal physical mechanism that tells them that when they use a credit card, they’re not really ‘paying for’ an item.

Contrast that with using cash.  When people use cash to pay for an item, the ‘pain’ receptors in the brain light up like a Christmas tree.  It can physically HURT to part ways with cash for an item.  This mechanism, which Dave uses in his lessons to encourage you to spend only cash, keeps you from spending cash on unnecessary items, and encourages you to shop around for good deals.

Health insurance is the ‘credit card’ of the healthcare field.  “I don’t care how much it COSTS, I need the service.”  Then when the ‘bill’ comes in the form of the premium, and that ‘bill’ continues to go up, the public blames some nameless, faceless entity (usually the insurer) for ripping them off, instead of trying to understand the COSTS of healthcare.

The solution to the problem of healthcare costs can be explained in one paragraph.  The solution doesn’t involve changing your insurance coverage in any way, and I can guarantee you that within a year, there would be a positive change in the COSTS of healthcare.

The solution?  If it’s a medical event that is not an inpatient hospital event, the patient must pay for the treatment/prescription/service out of their own pocket, and submit the claim to their insurer themselves.  In order to be covered as an inpatient hospital event, the medical standard of practice must be that the treatment/service can ONLY be provided on an inpatient basis.

WHAAAAAAT?  Are you KIDDING ME?  You think the solution is for me to PAY IN FULL for my expenses?  I CAN’T AFFORD THAT!

Exactly.  That’s EXACTLY the point.

I want you to take a breath and think about this for a moment.  How would your life change if you had to pay up front and submit the insurance claim yourself for every outpatient medical item, prescriptions included?

You would manage your expenses better.  You would price-shop for services and items.  If the doctor told you that you needed an MRI, you would call around and find out prices.

Competitive forces which are NOT in the marketplace now would return.  And COSTS would go down.

Think about the fringe benefits to the system as a whole –

The practice of defensive medicine would stop.  If a doctor said that you needed an MRI, you can guarantee that you absolutely needed that MRI.  And if you didn’t get it, whose fault would that be?  This would lessen the COST of malpractice insurance.

Doctors would be able to cut COSTS simply by eliminating some staff.  Have you ever looked behind the counter at the doctor’s office and seen 5 or 6 people there?  At least two of them are working on insurance claims – either filing, getting paid for claims, or reconciling.  That expense is gone.

You know that Lipitor I mentioned in the last blog post?  You would change to a ‘therapeutic substitute’ that is less expensive.  Eventually, Lipitor would get the hint and lower its COST to become more competitive.

Whether good or bad, there would be fewer claims filed with the insurer, in part because some people just wouldn’t file them.  And because of that, the COST of the insurance would eventually come down.   

There would no longer be the need for pharmacy benefit managers – those middlemen who charge a fee to your employer and pharmacy simply to handle your claim transaction.  This would lower the COSTS to your employer and pharmacy.

Unrealistic?  I don’t think so.  You’re actually much closer than you know.  An insurance industry buzzphrase is ‘cost-sharing’.  Insurance companies are more and more increasing your copays and deductibles as a means of ‘sharing’ the COST with the insured.  You may be paying a larger portion of your COSTS, but you’re definitely not in control of them.

So, there’s my fantasy.  The American public would have to actually take responsibility of their healthcare decisions, and do some work in an effort to control costs.  The insurance companies would have to directly answer to the public when a claim was filed.  Physicians, pharmacists and the like would be able to return to the practice of medicine and pharmacy, and we would COMPETE for your business.  

Does it solve everything?  No.  We still have the issue of the uninsured, but they would directly benefit from EVERYONE competing and lowering the COSTS of healthcare.

And I guarantee you that this plan, however fantasy-based, will be more functional than anything that comes out of Washington today.