First day at a CVS

[pharm B]

So for IPPE this semester, I'm spending time in a CVS as an intern. I had previously worked at Wal-Mart for a while, and I thought CVS would be similar. Boy was I surprised.

My first surprise was the loss prevention stuff everyone goes through. If you have a drink, you have to put a sticker on it with your transaction number from your receipt and get it signed by a manager.

The big one: When you walk out, you go through a "pocket check," where a store or shift manager (some of whom appear to be in their mid-20's) poke through your lab coat pockets on camera. I suppose I understand why they do it, but isn't it a bit unprofessional/disrespectful? I can't imagine working for a company that basically makes the blanket assumption that you're going to steal something.

I was genuinely surprised by their work flow, though.

Wal-Mart's work flow: Tech types up the rx -> RPh sees scanned Rx and the tech's transcription, approves it for fill -> Rx gets filled -> RPh sees hard copy, transcription, and medication image

CVS's work flow is similar, except that the pharmacist doesn't verify the tech's transcription of the Rx, so the tech just types it and goes and fills it. The pharmacist then has to catch any errors when he's already holding a filled med in his hand. If he finds a transcription problem (especially things like quantity, refills, etc), the current label and leaflet are junked and a new one prints out, and the whole process starts anew.

Just seems like Wal-Mart has the safer and more efficient set of steps.

One highlight: A woman came in today wondering if she was allergic to her bactrim. She'd been prescribed it before and never had any problems. I asked her what other meds, vitamins, etc, she was taking, and she said she had just taken a bunch of vitamins she always uses, along with some niacin for the first time, a little while before she got red and itchy. Pretty cool to help her out and keep "sulfa allergy" off her profile if it isn't needed.

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[owlegrad]

I had pocket checks at the grocery store and outlet mall jobs i used to work at, except everyone was really lax about it. Some CVS' are more lax than others I have noticed. It would be nice to get a little more respect now.

Cool that you caught the niacin use.

 

[PumpkinSmasher]

I have never heard of pocket checks. Nice catch on the niacin, I like your style...

 

[tydt]

I've never worked at Wal-Mart before so I can't say anything about the volume of customers they get on average. But CVS on the other hand, our store gets bombarded with around 200+ rxs on average everyday, and if you have to let the rph verify every rxs that comes by first then I think it would be more time consuming then letting experienced techs just typed it right away. Of course there will be errors sometimes and we will have to makes changes, but I still think it's still more time efficient than bringing 200+ rxs to the rph everytime before typing it up. Also, when the rph verify the rxs, they not only get to see what the techs typed in but also see the scanned rx on their comp. as well. As for our policy, ye it's ridiculous....I'm not sure if they've told you that if you need to leave to go to the bathroom or somewhere, you have to let the rph know also, or they can write you up if they are mean, seems to me like they're treating us like kids. I'm ready to get out of this dump anytime soon, which I am this fall. *sigh with relief* I have shadowed at Walgreens before and they seem to be alot better IMO, bigger pharmacy, more user friendly system, and fewer techs running around, seems much more efficient to me.

 

[fluorometholone]

CVS on the other hand, our store gets bombarded with around 200+ rxs on average everyday, and if you have to let the rph verify every rxs that comes by first then I think it would be more time consuming then letting experienced techs just typed it right away.

Ditto. My store does ~3000/wk, and interrupting our flow at that volume is unthinkable. Seems like it could get confusing, especially if you have just one pharmacist on- check new typed script for John Smith, check med for Betty White, check new rx for Abe Lincoln, back to med for John Smith, etc. Or would they wait for all of John's stuff to be done before looking at Betty's? I'm curious as to which chain does have the best workflow, though. CVS might have a decent idea in theory, but the computers are so slow that in practice, it's probably just as mediocre as anyone else's.

 

[Sparda29]

That's weird, when I did my APPE at CVS they never subjected me to the same loss prevention things. They never checked my backpack or coats or pocket search, etc.

 

[R xxx]

That's weird, when I did my APPE at CVS they never subjected me to the same loss prevention things. They never checked my backpack or coats or pocket search, etc.

It depends on the store/district. Every CVS is different.

 

[pinipig523]

Not sure about them patting you down being unprofessional. I can see how it could be misconstrued that way.

But when I was in high school and college, all part time retail jobs (i.e. best buy, old navy) I worked at, we got patted down.

 

[MountainPharmD]

I was genuinely surprised by their work flow, though.

Wal-Mart's work flow: Tech types up the rx -> RPh sees scanned Rx and the tech's transcription, approves it for fill -> Rx gets filled -> RPh sees hard copy, transcription, and medication image

CVS's work flow is similar, except that the pharmacist doesn't verify the tech's transcription of the Rx, so the tech just types it and goes and fills it. The pharmacist then has to catch any errors when he's already holding a filled med in his hand. If he finds a transcription problem (especially things like quantity, refills, etc), the current label and leaflet are junked and a new one prints out, and the whole process starts anew.

Just seems like Wal-Mart has the safer and more efficient set of steps.

CVS's work flow is the standard way nearly every pharmacies system works. Wal-Mart changed several years ago and so did Walgreens. Kroger got a new computer system two years ago and changed to the way Wal-Mart does it.

When you think about it, it makes sense. Why let an RX go all the way through the workflow with a mistake. 99% of all errors happen at data entry. It makes sense to split the verification up and verify data entry after it happens then send the Rx to product dispensing then verify the dispensing. The only problem with this is the entire workflow is dependant on the pharmacist. If the pharmacist is distracted, counseling, running the cash register or the drive through because of inadequate staffing then everything gets backed up in pre-verification waiting for the pharmacist to approve it and send it to dispensing. The system now ties the pharmacist to the computer. You step away for five minutes and the whole thing gets backed up.

I remember talking to some Wal-Mart Pharmacists five or six years ago when they rolled out the new system. They hated it at first but got used to it and liked it. The one major complaint was the inadequate staffing making the system not work as efficiently as intended. They told me it would be great if they had enough help to fully utilize it. I fully understand what they mean. A fancy computer system and work flow designed with 4 or 5workstations being run by 2 people is not utilizing the system to its full potential and in the end is more time consuming and less efficient than what we had before.

 

[PharmDstudent]

CVS is insanity. It really is.

 

[rx2010]

We have it to where the pharmacist has to verify what was typed first before it can be dispensed, and when it's just me and one tech, I would work drop off and type every thing and pre-verify it so the tech can dispense it. I would then jump back to my station and verify the final product dispensed by the tech. I find it more efficient for me to type since I will make less mistakes typing than my tech would. I type it and verify right away so there is nothing that would build up in pre-verification.

 

[Ackj]

I find it more efficient for me to type since I will make less mistakes typing than my tech would. I type it and verify right away so there is nothing that would build up in pre-verification.

This seems to just circumvent the safety that pre-ver offers the process. Naturally if you're typing, you would assume it is correct. I'm sure you are more accurate than a tech, but nobody notices that they're making a mistake at the time. A second set of eyes is more scrutinizing than our own, so it is definitely best to have one type and the other verify. However, if it's just the two of you manning a 5 step operation, I can see how the system is not going to be optimal anyway.

 

[MountainPharmD]

We have it to where the pharmacist has to verify what was typed first before it can be dispensed, and when it's just me and one tech, I would work drop off and type every thing and pre-verify it so the tech can dispense it. I would then jump back to my station and verify the final product dispensed by the tech. I find it more efficient for me to type since I will make less mistakes typing than my tech would. I type it and verify right away so there is nothing that would build up in pre-verification.

That is a good way to make mistakes that no one will catch. Two eyes looking at a script is better than one. When I am in this situation I do the opposite. I have the tech type and man the cash register. I man the product dispensing station. Here I pre-verify, dispense, and do the final verifiication. It is a much smother flow and you do not have to run back and forth between stations.

 

[rx2010]

That is a good way to make mistakes that no one will catch. Two eyes looking at a script is better than one. When I am in this situation I do the opposite. I have the tech type and man the cash register. I man the product dispensing station. Here I pre-verify, dispense, and do the final verifiication. It is a much smother flow and you do not have to run back and forth between stations.

I definitely agree it's much better to have two eyes than one, but I type and then verify what I typed is correct on the pre-verification screen. I don't automatically approve it since I'm the one who typed it. I'd rather my techs dispense because they type very slow and data entry gets backed up. If I have a tech that is fast and doesn't make many mistakes, I will let that tech type.

 

[kvl1027]

I have a good friend who is a Wally World pharmacist. Their store is doing 5-600/day and he says the workflow with Pre-verification was fine. I worked a Publix pharmacy for a very short peroid of time and they use EnterpriseRx, which has the pre-verification step and I thought it was great.

I think it is actually more efficient, than finding the error in the end after the medication is already counted and labeled, forcing you to put it back into stock, re-adjudicate the rx, and re-package the rx.

BTW, yet another CVS bashing thread....Love it


W L
CVS 1 - 4789 ( the 1 is RxNupe)

 

[owlegrad]

I have a good friend who is a Wally World pharmacist. Their store is doing 5-600/day and he says the workflow with Pre-verification was fine. I worked a Publix pharmacy for a very short peroid of time and they use EnterpriseRx, which has the pre-verification step and I thought it was great.

I think it is actually more efficient, than finding the error in the end after the medication is already counted and labeled, forcing you to put it back into stock, re-adjudicate the rx, and re-package the rx.

BTW, yet another CVS bashing thread....Love it


W L
CVS 1 - 4789 ( the 1 is RxNupe)

Well to be fair it might be 2 - 4789, OldTimer is also in the pro-CVS camp.

 

[kvl1027]

Well to be fair it might be 2 - 4789, OldTimer is also in the pro-CVS camp.

I thought Old Timer just tolerated it, not really a PRO-CVS'er, but lets give credit where credit is due.

 

[owlegrad]

I thought Old Timer just tolerated it, not really a PRO-CVS'er, but lets give credit where credit is due.

Before we had RxNupe, OldTimer seemed very pro-CVS, at least to me. Now maybe not so much. The bar has been raised.

 

[StevePerry]

Before we had RxNupe, OldTimer seemed very pro-CVS, at least to me. Now maybe not so much. The bar has been raised.

Yeah Old Timer ducked out on CVS on here when they needed him the most. It seems like somebody puts up a "CVS clubs baby seals" post every other day.

I've said it a million times but the CVS / Walgreens+Walmart (the ones who implemented 90% the horrible changes in pharmacy) Bashing Ratio is effing whack on here...

 

[kvl1027]

Yeah Old Timer ducked out on CVS on here when they needed him the most. It seems like somebody puts up a "CVS clubs baby seals" post every other day.

I've said it a million times but the CVS / Walgreens+Walmart (the ones who implemented 90% the horrible changes in pharmacy) Bashing Ratio is effing whack on here...

I agree, they are all guilty of bastardizing the profession (if you can even call it that anymore). When some doped up oxy-head walks in, raises hell, and instead of getting kicked out, gets a gift card.......that's when the profession jumped the shark. (Along with guaranteed 15 min wait times and drive thrus)

 

[MountainPharmD]

I thought Old Timer just tolerated it, not really a PRO-CVS'er, but lets give credit where credit is due.

Are you kidding me?!?!

Oldtimer is Rxnupe x10. He got tired of getting bashed by everyone with his crazy I love CVS talk so he quit. Rxnupe has yet to learn.

 

[MountainPharmD]

Yeah Old Timer ducked out on CVS on here when they needed him the most. It seems like somebody puts up a "CVS clubs baby seals" post every other day.

I've said it a million times but the CVS / Walgreens+Walmart (the ones who implemented 90% the horrible changes in pharmacy) Bashing Ratio is effing whack on here...

Yeah but there isnt anyone as militant and out of touch with reality like Oldtimer and Rxnupe trying to convince everyone how great Walgreens or Walmsrt is like those two do with CVS.

 

[Ackj]

I have a good friend who is a Wally World pharmacist. Their store is doing 5-600/day and he says the workflow with Pre-verification was fine. I worked a Publix pharmacy for a very short peroid of time and they use EnterpriseRx, which has the pre-verification step and I thought it was great.

I had an IPPE at a 1000+ store using Enterprise with the pre-ver, and it went pretty smoothly due to the adequate staffing. I can see the system being a huge PITA if you didn't have somebody to man each station.

 

[kvl1027]

I had an IPPE at a 1000+ store using Enterprise with the pre-ver, and it went pretty smoothly due to the adequate staffing. I can see the system being a huge PITA if you didn't have somebody to man each station.

Absolutely, you should someone for every stage of workflow. It only makes sense. It would for sure be a failure if without enough staffing.

I also think it is very beneficial with two pharmacists working, one doing pre-verification and the other doing a final check.

 

[Old Timer]

Yeah Old Timer ducked out on CVS on here when they needed him the most. It seems like somebody puts up a "CVS clubs baby seals" post every other day.

I've said it a million times but the CVS / Walgreens+Walmart (the ones who implemented 90% the horrible changes in pharmacy) Bashing Ratio is effing whack on here...

No he got tired of speaking to irrational people whose knowledge of how pharmacy got into this mess would be hard pressed to be found in a thimble with a scanning electron microscope.

You can't have a rational discussion with irrational people who have no frame of reference and think the good old days were when you worked for an independent at $12.50 per hour with limited health insurance, no pension and your boss on your ass like a wet diaper were really the good old days.

These people fail to understand that modern chain pharmacy is the result not the cause of the problem. It was not the chain industry that turned pharmacy into piece work. The same thing has happened to medicine and there is no national medical chains enslaving doctors, yet they suffer from the same problems that pharmacy faces. Inadequate reimbursement for the value of the service rendered. There is a slight difference in that we sell a "product" and for the most part physicians don't. But the same problems are facing the solo medical practitioner as faces the solo pharmacy practitioner. If you fail to see that well, what can I say. You be blind.

The chain industry is the whipping boy around here. That's all well and good. It's the story we tell ourselves so we as a profession don't have to take responsibility for the state we are in. CVS and Walgreens are run by the Devil in order to enslave the poor pharmacists. It's a nice simple narrative.

I have been doing this for almost thirty years and I remember when there was almost no third party insurance and 90% of the patients paid cash. I watched as an industry failed to come together to protect itself from the enemy. I remember when labels had to licked and the self sticking labels were an upgrade. I lived through typewriters and universal claim forms. I also remember being in a meeting with the suits from I.B.M. when my step father wanted to computerize and he handed them the Red Book and said we needed that in the computer and they said "You can't afford that."

I have seen a great deal over the last thirty years. If you want to blame what has happened on the chain drug industry, you are free to have your own delusions. Just remember it has nothing to do with reality.

Correlation is not causation.......

 

[Dkpharm]

^ that was biblical.

 

[kvl1027]

No he got tired of speaking to irrational people whose knowledge of how pharmacy got into this mess would be hard pressed to be found in a thimble with a scanning electron microscope.

You can't have a rational discussion with irrational people who have no frame of reference and think the good old days were when you worked for an independent at $12.50 per hour with limited health insurance, no pension and your boss on your ass like a wet diaper were really the good old days.

These people fail to understand that modern chain pharmacy is the result not the cause of the problem. It was not the chain industry that turned pharmacy into piece work. The same thing has happened to medicine and there is no national medical chains enslaving doctors, yet they suffer from the same problems that pharmacy faces. Inadequate reimbursement for the value of the service rendered. There is a slight difference in that we sell a "product" and for the most part physicians don't. But the same problems are facing the solo medical practitioner as faces the solo pharmacy practitioner. If you fail to see that well, what can I say. You be blind.

The chain industry is the whipping boy around here. That's all well and good. It's the story we tell ourselves so we as a profession don't have to take responsibility for the state we are in. CVS and Walgreens are run by the Devil in order to enslave the poor pharmacists. It's a nice simple narrative.

I have been doing this for almost thirty years and I remember when there was almost no third party insurance and 90% of the patients paid cash. I watched as an industry failed to come together to protect itself from the enemy. I remember when labels had to licked and the self sticking labels were an upgrade. I lived through typewriters and universal claim forms. I also remember being in a meeting with the suits from I.B.M. when my step father wanted to computerize and he handed them the Red Book and said we needed that in the computer and they said "You can't afford that."

I have seen a great deal over the last thirty years. If you want to blame what has happened on the chain drug industry, you are free to have your own delusions. Just remember it has nothing to do with reality.

Correlation is not causation.......

I get what you are saying and I agree with you for the most part, but CVS owns an insurance company and that is the problem I have with them. Based on your argument though you should be pretty happy about what Walgreens has decided to do with Express Scripts, right? I just wish CVS stood up with Wags and said we aren't going to take this crap either, but they do it themselves through CVS/Caremark and forced mail-order, its all BS.

 

[MountainPharmD]

No he got tired of speaking to irrational people whose knowledge of how pharmacy got into this mess would be hard pressed to be found in a thimble with a scanning electron microscope.

You can't have a rational discussion with irrational people who have no frame of reference and think the good old days were when you worked for an independent at $12.50 per hour with limited health insurance, no pension and your boss on your ass like a wet diaper were really the good old days.

These people fail to understand that modern chain pharmacy is the result not the cause of the problem. It was not the chain industry that turned pharmacy into piece work. The same thing has happened to medicine and there is no national medical chains enslaving doctors, yet they suffer from the same problems that pharmacy faces. Inadequate reimbursement for the value of the service rendered. There is a slight difference in that we sell a "product" and for the most part physicians don't. But the same problems are facing the solo medical practitioner as faces the solo pharmacy practitioner. If you fail to see that well, what can I say. You be blind.

The chain industry is the whipping boy around here. That's all well and good. It's the story we tell ourselves so we as a profession don't have to take responsibility for the state we are in. CVS and Walgreens are run by the Devil in order to enslave the poor pharmacists. It's a nice simple narrative.

I have been doing this for almost thirty years and I remember when there was almost no third party insurance and 90% of the patients paid cash. I watched as an industry failed to come together to protect itself from the enemy. I remember when labels had to licked and the self sticking labels were an upgrade. I lived through typewriters and universal claim forms. I also remember being in a meeting with the suits from I.B.M. when my step father wanted to computerize and he handed them the Red Book and said we needed that in the computer and they said "You can't afford that."

I have seen a great deal over the last thirty years. If you want to blame what has happened on the chain drug industry, you are free to have your own delusions. Just remember it has nothing to do with reality.

Correlation is not causation.......

Your missing the forest for all the trees. Its the ****ty PBM contracts the likes of Wags and CVS have been singing for the last 15 years that have destroyed the profession. Sprinkle in Wal-Marts $4 generics and Medicare part D and you have the perfect storm. You are a fool if you think the poor little chains are just hapless victims. Wags is 15 years to late in standing up to a PBM.

 

[Old Timer]

Your missing the forest for all the trees. Its the ****ty PBM contracts the likes of Wags and CVS have been singing for the last 15 years that have destroyed the profession. Sprinkle in Wal-Marts $4 generics and Medicare part D and you have the perfect storm. You are a fool if you think the poor little chains are just hapless victims. Wags is 15 years to late in standing up to a PBM.

No, you miss the forest for the trees. This happened way before 15 years ago and it was independent pharmacy that did this. The chains were there to pick up the pieces when the indies went belly up in the 90's. Like I said, on a scale from 1-10 your knowledge level would be -40. It happened in the 80's when people signed up for AWP - contracts. They weren't worried about CVS, Rite Aid, Thrift, etc. They worried that Joe's Pharmacy down the street would sign and take all of their business, so they signed too.

 

[Old Timer]

I get what you are saying and I agree with you for the most part, but CVS owns an insurance company and that is the problem I have with them. Based on your argument though you should be pretty happy about what Walgreens has decided to do with Express Scripts, right? I just wish CVS stood up with Wags and said we aren't going to take this crap either, but they do it themselves through CVS/Caremark and forced mail-order, its all BS.

You did read my post, right. CVS bought Caremark 2 or 3 years ago. This problem was created in the 1980's when CVS and the chain drug industry in general was not the powerhouse they have become. For those of you who did not practice in the 1980's, the chains were the beneficiaries of the stupidity of independent pharmacy practices, not the cause.

 

[PharmaTope]

I think it is safe to say the problems the pharmacy profession face stem from more than one cause.

However, the "leaders" of pharmacy and I put leaders in quotes for a reason, will do nothing to help lead the profession in a new direction. Pharmacists have for a long time been a lay down and take it profession. Stuck in the bubble of the pharmacy in the back of the store.

MTM will never do much to change anything. You need to get up to speed with the other competing professions or face extinction. Survival of the fittest. Relying on someone to pay you a paycheck each week won't do much for you and you will be victimized by the corporations.

If you shop at CVS and Walgreens, you only feed those corporations. They make their money off front end sales. I encourage everyone to spread the word to avoid.

 

[pharm B]

Odd question, but what kind of movement is there for a pharmacist as an employee? I assume they never take on whole-store management, but just bump up to Regional Manager for pharmacy.

I went back for another day when it wasn't anywhere near as busy, and it was a different day altogether. I was still surprised at how cluttered the place was compared to the Wal-Mart I had previously worked at. I can see that the system does work, but I'm wondering if it's left to individual stores/pharmacists to decide how they're going to best make use of the CVS work flow.

Another odd one: At Wal-Mart, the cashier looks up the patient based on name and date of birth, and then their screen shows them how many medications this person has ready, in trouble, etc. At CVS, the cashier only has a cash register. They ask how many the person has, and they retrieve them from a bin.

It seems like someone could easily walk out without a new medication they might not remember if it's stuck in troubleshooting (or whatever CVS calls it).

Also seems like people with the same name but different DOB's could more easily get their meds swapped.

Not bashing CVS per se, just pointing out what I think are issues that could easily be addressed/ fixed. I honestly thought companies competed to be the safest, most efficient, etc, since safety and efficiency lend themselves to financial gains in the form of fewer lawsuits and better use of personnel.

 

[Smilescali]

Yes, Wal-Mart has a pretty good system that is organized. During pharm school I rotated through CVS, Wags and Target and found that Wal-Mart has the safest system around. I was hired with Safeway right out of school and really was frustrated with the workflow and staffing there. I finally got hired on with Wal-Mart about 6 months later and can actually say I enjoy my RETAIL job... ha ha. It is what it is... good days and bad, but for retail I feel it is not a bad place to be. My store does around 275-350 a day and we have 2 pharmacists (overlap), 3-4 techs and 2 clerks working per day.

 

[CUpharmD2013]

Odd question, but what kind of movement is there for a pharmacist as an employee? I assume they never take on whole-store management, but just bump up to Regional Manager for pharmacy.

I went back for another day when it wasn't anywhere near as busy, and it was a different day altogether. I was still surprised at how cluttered the place was compared to the Wal-Mart I had previously worked at. I can see that the system does work, but I'm wondering if it's left to individual stores/pharmacists to decide how they're going to best make use of the CVS work flow.

Another odd one: At Wal-Mart, the cashier looks up the patient based on name and date of birth, and then their screen shows them how many medications this person has ready, in trouble, etc. At CVS, the cashier only has a cash register. They ask how many the person has, and they retrieve them from a bin.

It seems like someone could easily walk out without a new medication they might not remember if it's stuck in troubleshooting (or whatever CVS calls it).

Also seems like people with the same name but different DOB's could more easily get their meds swapped.

Not bashing CVS per se, just pointing out what I think are issues that could easily be addressed/ fixed. I honestly thought companies competed to be the safest, most efficient, etc, since safety and efficiency lend themselves to financial gains in the form of fewer lawsuits and better use of personnel.

This is something that I noticed at Walgreens too when I went in there to inquire about a community pharmacy rotation. I agree that this is something that should be available at the POS (point of sale, not the other POS) so that whoever is working pickup can quickly see how many scripts they are looking for, and if there is even anything ready. At all the CVS's I have worked at, you have to step away from the pickup counter to access a computer for looking up this type of information. Often times this is the third line of defense when it should really be the first line if it was more accessible.

 

[SuperDuperSuper]

I've never worked at Wal-Mart before so I can't say anything about the volume of customers they get on average. But CVS on the other hand, our store gets bombarded with around 200+ rxs on average everyday, and if you have to let the rph verify every rxs that comes by first then I think it would be more time consuming then letting experienced techs just typed it right away. Of course there will be errors sometimes and we will have to makes changes, but I still think it's still more time efficient than bringing 200+ rxs to the rph everytime before typing it up. Also, when the rph verify the rxs, they not only get to see what the techs typed in but also see the scanned rx on their comp. as well.
As for our policy, ye it's ridiculous....I'm not sure if they've told you that if you need to leave to go to the bathroom or somewhere, you have to let the rph know also, or they can write you up if they are mean, seems to me like they're treating us like kids. I'm ready to get out of this dump anytime soon, which I am this fall. *sigh with relief*
I have shadowed at Walgreens before and they seem to be alot better IMO, bigger pharmacy, more user friendly system, and fewer techs running around, seems much more efficient to me.

My wal mart pharmacy does about 600 on a busy day.
Usually, we have one RPH checking the transcription, and another verifying the fills / majority of counseling (if I don't have a preceptor available.)
I agree with PharmB. I can see all of those potential errors driving up the cost of dispensing by a noticeable amount.

MountainPharmD does bring up a good point, on the other hand. If there is an unseasoned pharmacist pulling solo duty, there is the opportunity for the RPh to become a bottleneck in the workflow. However, this isn't the case the vast majority of the time, and people adapt to pressures as they need to.

 

[Smilescali]

That is a good way to make mistakes that no one will catch. Two eyes looking at a script is better than one. When I am in this situation I do the opposite. I have the tech type and man the cash register. I man the product dispensing station. Here I pre-verify, dispense, and do the final verifiication. It is a much smother flow and you do not have to run back and forth between stations.

This is what I do as well: tech types (Input step), I verify the typed script (pre verify, 4-point), I fill/ or if there if a filling tech they fill), I do troubleshoot/ insurance along with input tech, then I verify dispensed medication. I rarely play cashier if I have a scheduled cashier, but when I don't the tech goes out to man the cashier and I fill. The pharmacist types scripts only when there is another pharmacist on duty and we verify each others. Yes, two people must be involved in the typing/verifying of the prescriptions.

 

[kvl1027]

You did read my post, right. CVS bought Caremark 2 or 3 years ago. This problem was created in the 1980's when CVS and the chain drug industry in general was not the powerhouse they have become. For those of you who did not practice in the 1980's, the chains were the beneficiaries of the stupidity of independent pharmacy practices, not the cause.

So, because the problem was created in the 1980's major chains can't be held somewhat responsible for perpetuating the cycle??? This whole, everything is already f''d up so if you can't beat join mentallity is part of the problem. You don't see anything wrong at all with a mojor pharmacy chain owning a PBM? Really?

Also, can you please clarify the stupidity of independent pharmacy practices

 

[Old Timer]

So, because the problem was created in the 1980's major chains can't be held somewhat responsible for perpetuating the cycle???

They didn't perpetuate the cycle. They took advantage of it. When the insurance industry converted the pharmacy industry into piece work, the only way to be successful is to increase volume. The chains can use their economy of scale and mass purchasing power to make money when lower volume operators can't. Their used to be a little grocery store on every corner and they have been replaced by supermarkets. Same thing.

This whole, everything is already f''d up so if you can't beat join mentallity is part of the problem.

They are a publicly traded corporation whose sole function is to make money for their share holders. That's what corporations do. They didn't join anybody, they beat others into submission.

You don't see anything wrong at all with a mojor pharmacy chain owning a PBM? Really?

No I don't. I have a problem with PBM's in general, but when I call Caremark, I get the same ****ty service you get. They don't perk up & kiss my butt because I work for CVS.

Also, can you please clarify the stupidity of independent pharmacy practices

They refused to work together to fight the PBM's when they had the leverage. When the market was 10% third party and the chains were a shadow of themselves. In 1988 there were 750 CVS Pharmacies, Walgreens had 1000. In my little suburban community there was one Thrift (Eckerd) One CVS and one Rite Aid. There were no Walgreens. There were about 25 Independents. They could have refused these contracts and negotiated better terms. They all signed and the rest as they say is history. This was repeated all over the country. They raced to the bottom and the majors cleaned up the pieces. Now in my little area there are less than 5 independents and there are two Rite Aids, two Walgreens and a **** load of CVS.

The reason why our entire health care system is screwed up is because it is a hybrid. It's part socialist and part capitalist. It has the worst of both systems. The consumer is no longer the payor. When the consumer is divorced from the payment for goods & services everything is blanked up.....

 

[Rxnupe]

CVS's work flow is the standard way nearly every pharmacies system works. Wal-Mart changed several years ago and so did Walgreens. Kroger got a new computer system two years ago and changed to the way Wal-Mart does it.

When you think about it, it makes sense. Why let an RX go all the way through the workflow with a mistake. 99% of all errors happen at data entry. It makes sense to split the verification up and verify data entry after it happens then send the Rx to product dispensing then verify the dispensing. The only problem with this is the entire workflow is dependant on the pharmacist. If the pharmacist is distracted, counseling, running the cash register or the drive through because of inadequate staffing then everything gets backed up in pre-verification waiting for the pharmacist to approve it and send it to dispensing. The system now ties the pharmacist to the computer. You step away for five minutes and the whole thing gets backed up.

I remember talking to some Wal-Mart Pharmacists five or six years ago when they rolled out the new system. They hated it at first but got used to it and liked it. The one major complaint was the inadequate staffing making the system not work as efficiently as intended. They told me it would be great if they had enough help to fully utilize it. I fully understand what they mean. A fancy computer system and work flow designed with 4 or 5workstations being run by 2 people is not utilizing the system to its full potential and in the end is more time consuming and less efficient than what we had before.

MPD- I agree to a point- you make a valid point the double check is a good and safer option if the Pharmacy is staffed correctly but it will be hell if it's not staffed. CVS way is good if you have better than average technicians but if you have poor technicians it will be a headache. I tend to think CVS workflow is faster- but in the long run it's better to be safe than fast on any given day. However, I think if CVS was to add the extra verification step by the Pharmacist they will have to ad extra help because as you mentioned the extra verification will work great if you are staffed very well.

 

[Rxnupe]

Ditto. My store does ~3000/wk, and interrupting our flow at that volume is unthinkable. Seems like it could get confusing, especially if you have just one pharmacist on- check new typed script for John Smith, check med for Betty White, check new rx for Abe Lincoln, back to med for John Smith, etc. Or would they wait for all of John's stuff to be done before looking at Betty's? I'm curious as to which chain does have the best workflow, though. CVS might have a decent idea in theory, but the computers are so slow that in practice, it's probably just as mediocre as anyone else's.

Again I agree when I worked for WAGS and I compare it to CVS- I personally like CVS workflow better it just seems to me that if you have good techs who make little to no errors or very few errors the CVS is more efficient. For example, let's say WAGS has 2 rx's for Amoxil 500mg and Vicodin an let's assume the tech has typed in the rx correctly- however, if I am doing a Flu shot and on my way to return to the Pharmacy a customer stops me and ask me for recommendation of some OTC product and than when I re-enter the Pharmacy- there's a doctor who needs to talk to me about changing a prescription an after that phone call a tech calls me over to the Drive Thru for consult now all that time spent- those labels would not be printed until I return to my station- so that could have been 10 to 15 minutes that those rx's are in limbo under WAGS system- now under CVS system I return to my station and the Rx's are waiting for me to verify-it's a reason why I prefer CVS system better- but again if all Pharmacies were properly staffed WAGS would be more ideal.

 

[StevePerry]

They didn't perpetuate the cycle. They took advantage of it. When the insurance industry converted the pharmacy industry into piece work, the only way to be successful is to increase volume. The chains can use their economy of scale and mass purchasing power to make money when lower volume operators can't. Their used to be a little grocery store on every corner and they have been replaced by supermarkets. Same thing.


They are a publicly traded corporation whose sole function is to make money for their share holders. That's what corporations do. They didn't join anybody, they beat others into submission.


No I don't. I have a problem with PBM's in general, but when I call Caremark, I get the same ****ty service you get. They don't perk up & kiss my butt because I work for CVS.



They refused to work together to fight the PBM's when they had the leverage. When the market was 10% third party and the chains were a shadow of themselves. In 1988 there were 750 CVS Pharmacies, Walgreens had 1000. In my little suburban community there was one Thrift (Eckerd) One CVS and one Rite Aid. There were no Walgreens. There were about 25 Independents. They could have refused these contracts and negotiated better terms. They all signed and the rest as they say is history. This was repeated all over the country. They raced to the bottom and the majors cleaned up the pieces. Now in my little area there are less than 5 independents and there are two Rite Aids, two Walgreens and a **** load of CVS.

The reason why our entire health care system is screwed up is because it is a hybrid. It's part socialist and part capitalist. It has the worst of both systems. The consumer is no longer the payor. When the consumer is divorced from the payment for goods & services everything is blanked up.....

Honestly Old Timer makes some very, VERY salient points on here. I think we all romanticize independents when in fact they have been and continue to be every bit as greedy in many instances as the chains (no benefits, lowball salary, "questionable" professional practices, selling out to the big guys, etc.) . People are ****ing people after all!

Still with where the game is now, the chains should do the PhRMA thing (screw collusion!) and at least band together to get the PBM virus under control (or even purged) and duke it out with advertising and sales and whatnot and NOT by racing further to the bottom.

Also, dissing CVS for the Caremark thing when you think about it doesn't really make sense. Think (hypothetically) what if CVS had Caremark, Wags had Medco, Rite Aid had Express Scripts? There would at least be a balance of power and it would be assumed that each one wanted to funnel business to themselves. The Express Scripts model of turning ALL against each other is far more dangerous...

 

[MountainPharmD]

The reason why our entire health care system is screwed up is because it is a hybrid. It's part socialist and part capitalist. It has the worst of both systems. The consumer is no longer the payor. When the consumer is divorced from the payment for goods & services everything is blanked up.....

That pretty much sums it up. It has driven the price of everything up from the education needed to that cost of medications and procedures performed.

The only way to fix the system is to scrap it and start over. That is not a viable option.

 

[kvl1027]

They refused to work together to fight the PBM's when they had the leverage. When the market was 10% third party and the chains were a shadow of themselves. In 1988 there were 750 CVS Pharmacies, Walgreens had 1000. In my little suburban community there was one Thrift (Eckerd) One CVS and one Rite Aid. There were no Walgreens. There were about 25 Independents. They could have refused these contracts and negotiated better terms. They all signed and the rest as they say is history. This was repeated all over the country. They raced to the bottom and the majors cleaned up the pieces. Now in my little area there are less than 5 independents and there are two Rite Aids, two Walgreens and a **** load of CVS.

I was discussing this issue with the owner of my pharmacy. I asked him why don'ty independents band together and negotiate better reimbursements. He talked about some legislation that was passed that prevented this due to giving the pharmacies/owners too much power. I don't know the exact legislation, but I will look more into this and post it, because it directly applie to this argument.

The reason why our entire health care system is screwed up is because it is a hybrid. It's part socialist and part capitalist. It has the worst of both systems. The consumer is no longer the payor. When the consumer is divorced from the payment for goods & services everything is blanked up.....

You couldn't be more correct. This is the crap we are facing and we will get nowhere on this until people can agree to disagree and work together to create something that benefits the people and not the profits of major corporations.

 

[MountainPharmD]

No, you miss the forest for the trees. This happened way before 15 years ago and it was independent pharmacy that did this. The chains were there to pick up the pieces when the indies went belly up in the 90's. Like I said, on a scale from 1-10 your knowledge level would be -40. It happened in the 80's when people signed up for AWP - contracts. They weren't worried about CVS, Rite Aid, Thrift, etc. They worried that Joe's Pharmacy down the street would sign and take all of their business, so they signed too.

Oldtimer I am going to give you a +1 one for your recollection of the old days and a –100 for the application of that knowledge. To suggest independent pharmacy owners competing against each other is somehow the cause of the mess we are in today is ludicrous. Profit margins in the 80’s and early 90’s were running upwards of 30% or more. It wasn’t until the massive expansion of the retail chains in the early to mid 90’s that things started to go bad. I believe it was the intent of Walgreens and CVS to sign bad PBM contracts figuring they could make up the difference in volume. This would drive out weaker retail chain competitors as well as independents, which could not rely on volume to make up the decrees in revenue. Take a look around because that is exactly what has happened. The big two scooped up weaker chains along with virtually all independent pharmacies. Now we see Walgreens trying to go the other direction with Express scripts now that most of the competion has been squashed.

 

[joetrisman]

Oldtimer I am going to give you a +1 one for your recollection of the old days and a –100 for the application of that knowledge. To suggest independent pharmacy owners competing against each other is somehow the cause of the mess we are in today is ludicrous. Profit margins in the 80’s and early 90’s were running upwards of 30% or more. It wasn’t until the massive expansion of the retail chains in the early to mid 90’s that things started to go bad. I believe it was the intent of Walgreens and CVS to sign bad PBM contracts figuring they could make up the difference in volume. This would drive out weaker retail chain competitors as well as independents, which could not rely on volume to make up the decrees in revenue. Take a look around because that is exactly what has happened. The big two scooped up weaker chains along with virtually all independent pharmacies. Now we see Walgreens trying to go the other direction with Express scripts now that most of the competion has been squashed.

Growing up in my father's independent pharmacy and seeing the shift occur before my eyes, I totally agree.

 

[MountainPharmD]

They refused to work together to fight the PBM's when they had the leverage. When the market was 10% third party and the chains were a shadow of themselves. In 1988 there were 750 CVS Pharmacies, Walgreens had 1000. In my little suburban community there was one Thrift (Eckerd) One CVS and one Rite Aid. There were no Walgreens. There were about 25 Independents. They could have refused these contracts and negotiated better terms. They all signed and the rest as they say is history. This was repeated all over the country. They raced to the bottom and the majors cleaned up the pieces. Now in my little area there are less than 5 independents and there are two Rite Aids, two Walgreens and a **** load of CVS.....

First off independent pharmacy owners cannot work together. It's against the law. I realize you work for CVS, a company that has made it their business culture to break the law and do whatever it takes to make money, so you do not care about this. Let me give you a lesson on anti-trust laws. Something you should be well versed in since CVS is in violation of them.

Fromhttp://www.lawyersandsettlements.com/antitrust.html

Antitrust laws were designed to protect economic freedom and promote competition in the marketplace. As such, companies that are found to behave in an anti-competitive manner may be guilty of antitrust. Actions that may constitute antitrust behavior include creating an illegal monopoly, illegally reducing competition, bid rigging, group boycotts, geographic market allocation and price fixing.

Man that sounds a lot like a certain merger between a major pharmacy chain and a PBM!

The Sherman Antitrust Act prohibits all contracts, combinations and conspiracies that unreasonably restrict interstate and foreign trade. This includes price fixing, bid rigging and customer allocation. Furthermore, under the Sherman Act, it is a crime to monopolize any part of interstate commerce.

The Clayton Act prohibits mergers or acquisitions that are likely to restrict competition and therefore increase prices to consumers.

The Federal Trade Commission Act prohibits unfair methods of competition in interstate commerce.

Take a medium large town with 25 independent pharmacy owners. If they got together and decided they are not going to sign any PBM contracts unless they get reimbursed a certain amount they have broken the law. It is an antitrust violation and if the dollar amounts are large enough it could be racketeering as well. Yet it would be legal for CVS or Walgreens to come in and buy all 25 independants and decide not to sign PBM contracts below a certain reimbursement. A fact they exploited quite well.

CVS and Walgreens figured out they could low ball the independants and weaker chains out of business. Once they had a monopoly on the whole thing they could go to the PBMs and say they were not going to accept thier ****ty reimbursemnet. Gee look what Walgreens and Express scripts are battling about today. It is rediculous to think indendant pharmacy owners were the cause of all this and the big chains came in and picked up the pieces. The chains are 100% the cause and I believe it was calculated and intentional.

 

[StevePerry]

First off independent pharmacy owners cannot work together. It's against the law. I realize you work for CVS, a company that has made it their business culture to break the law and do whatever it takes to make money, so you do not care about this. Let me give you a lesson on anti-trust laws. Something you should be well versed in since CVS is in violation of them.



Man that sounds a lot like a certain merger between a major pharmacy chain and a PBM!







Take a medium large town with 25 independent pharmacy owners. If they got together and decided they are not going to sign any PBM contracts unless they get reimbursed a certain amount they have broken the law. It is an antitrust violation and if the dollar amounts are large enough it could be racketeering as well. Yet it would be legal for CVS or Walgreens to come in and buy all 25 independants and decide not to sign PBM contracts below a certain reimbursement. A fact they exploited quite well.

CVS and Walgreens figured out they could low ball the independants and weaker chains out of business. Once they had a monopoly on the whole thing they could go to the PBMs and say they were not going to accept thier ****ty reimbursemnet. Gee look what Walgreens and Express scripts are battling about today. It is rediculous to think indendant pharmacy owners were the cause of all this and the big chains came in and picked up the pieces. The chains are 100% the cause and I believe it was calculated and intentional.

Hold on I'll be right back, T.O. and I are grabbing some more popcorn... I must say Old Timer did appeal to my logic, but Mountain touches my inner cynic, and I don't mean that in a Sandusky way either. Always good to see these two go at it.On the scumbag meter I think we can agree that it still reads: independents < chains < PBMs.PBMs are completely unnecessary, I mean seriously for the cut they take, holy **** are they utterly useless...

 

[MountainPharmD]

Hold on I'll be right back, T.O. and I are grabbing some more popcorn... I must say Old Timer did appeal to my logic, but Mountain touches my inner cynic, and I don't mean that in a Sandusky way either. Always good to see these two go at it.On the scumbag meter I think we can agree that it still reads: independents < chains < PBMs.PBMs are completely unnecessary, I mean seriously for the cut they take, holy **** are they utterly useless...

Hey man I am not touching your inner cynic so don't even ask! Oldtimer on the other hand.....I have heard some things............

 

[Old Timer]

First I am aware of the Sherman Antitrust Act. More aware that you will ever be. You never met with lawyers, formed the groups and fought that battle. You did not meet with congressman and state representatives to fight the cause of independent pharmacy. Those who cannot understand history cannot comprehend it.

You were not involved in the suit against U.S. Healthcare (Now Aetna) for ripping off the pharmacists in their capitation plan. You probably don't even know what capitation is.

You have not a single clue of what was going on the pharmacy world in the 1980's You were probably playing with your own poop. By the time the 90's rolled around, the chains rescued these guys that were struggling. They threw vast amounts of money at them paying way more than they should to buy files. In the case of the store I was going to buy, Thrift (to become Eckerds and then go bankrupt) offered 250,000.00 more than the price I had agreed to pay.

During this time the store I was at was constantly increasing volume in scripts and sales. It just didn't grow fast enough.....

I was there and I know what happened.

 

[Shnurek]

First I am aware of the Sherman Antitrust Act. More aware that you will ever be. You never met with lawyers, formed the groups and fought that battle. You did not meet with congressman and state representatives to fight the cause of independent pharmacy. Those who cannot understand history cannot comprehend it.

You were not involved in the suit against U.S. Healthcare (Now Aetna) for ripping off the pharmacists in their capitation plan. You probably don't even know what capitation is.

You have not a single clue of what was going on the pharmacy world in the 1980's You were probably playing with your own poop. By the time the 90's rolled around, the chains rescued these guys that were struggling. They threw vast amounts of money at them paying way more than they should to buy files. In the case of the store I was going to buy, Thrift (to become Eckerds and then go bankrupt) offered 250,000.00 more than the price I had agreed to pay.

During this time the store I was at was constantly increasing volume in scripts and sales. It just didn't grow fast enough.....

I was there and I know what happened.

Old Timer, do you have any advice when it comes to the profession of Optometry? A lot of our graduates are being forced to work commercial because of high student debts and of course they are offered hefty starting salaries (100k-110k) at places like Sear's optical, walmart, cohen's fashion optical, lenscrafters, america's best etc. I am not sure how much of the profession works in this way but it is about 25% I'd say. Also our matriculants are about 67% women and they prefer to be employed. Do you think the same thing will happen to optometry as what happened with pharmacy?