you know a drug rep just visited a doc when...

[xiphoid2010]

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...he orders Silenor 6mg PO qHS. What the heck is Silenor? OMG, it's freakin doxepin! Calls the doc up and rec'd generic 10mg cap, cha ching, saved $515 off this month's budget in <5 minutes. Take that you drug rep!

Seriously, doctors are smart people, they should have just laughed in the drug rep's face on lame stuff like this.

 

[schamj01]

that is both depressing and hilarious. way to look out for your patient though

 

[genesis09]

That is a PA required drug. Regular doxepin is easily available and rather inexpensive. It is in the same category of Kapvay and Gabapentin XR.

 

[xiphoid2010]

I got no problem with trying new drugs that are novel or improved. I recently got Nucynta for the same doc (must have been another drug rep) because a literature search showed it had merit for select patients.

What's really lame are the pharmaceutical company shenanigans like repacking the same old drug that has been used off-label, get the FDA to approve the indication, and then charge 100x more for it.

 

[NAPLEXON]

Oracea vs generic doxycycline hyclate!

 

[WVUPharm2007]

...he orders Silenor 6mg PO qHS. What the heck is Silenor? OMG, it's freakin doxepin! Calls the doc up and rec'd generic 10mg cap, cha ching, saved $515 off this month's budget in <5 minutes. Take that you drug rep!

Seriously, doctors are smart people, they should have just laughed in the drug rep's face on lame stuff like this.

Aren't you in charge? Just get it auto-subbed next committee meeting.

Now when you negotiate that discount with some drug company that saves like $2 mil a year, then I'll be impressed.

 

[xiphoid2010]

Aren't you in charge? Just get it auto-subbed next committee meeting.

Now when you negotiate that discount with some drug company that saves like $2 mil a year, then I'll be impressed.

You dont want a bazillion auto-sub policy. I will push one though p&t and MEC if something happens frequent enough/the cost saving is major.

Talking about that, I am prepping one, removing doribax and auto-sub merrem. But the cost saving from it is really going to come from the alternative dosing policy. Currently debating 500mg q6h vs. 500mg q8h extended infusion, with couple of exceptions. Pros and cons to both, but either way it will save a bundle vs. the old 1 gm q8h.

 

[All4MyDaughter]

Auto-sub policies work pretty well for the VA.

Can phyisicians at your hospital just write for whatever they want? Formulary restrictions?

 

[meister]

gotta pay the bills, man

 

[xiphoid2010]

Auto-sub policies work pretty well for the VA.

Can phyisicians at your hospital just write for whatever they want? Formulary restrictions?

Ah, the VA, yeah, I remember how the system was structured and had 99999 CFUs preventing excessive prescribing. Overall, it was a good thing in my opinion. Things are much less orderly in a small community hospital, with only a few restrictions. But without a formulary guarded by an empowered pharmacy department with dozens of clinical pharmacist doing CFUs and non-formulary approvals like in the VA, physicians are mostly free to write whatever.

 

[297point1]

Not too long ago, Covera HS was in thing for PCPs/GPs to prescribe...because you really have to be careful of that early morning MI.

Cardiologists seemed to know better and rarely wrote for it; health plans and PBMs squashed it to non-formulary.

 

[PumpkinSmasher]

Ah, the VA, yeah, I remember how the system was structured and had 99999 CFUs preventing excessive prescribing. Overall, it was a good thing in my opinion. Things are much less orderly in a small community hospital, with only a few restrictions. But without a formulary guarded by an empowered pharmacy department with dozens of clinical pharmacist doing CFUs and non-formulary approvals like in the VA, physicians are mostly free to write whatever.

I work at a medium to large sized hospital, we are not part of a huge health system, we do not have loads of clinical pharmacists and are pharmacy dept is still in the building phase of being an empowered clinical resource. Yet we manage to keep a tight formulary throughout the entire hospital and share the load of taking care of non-formulary approvals.

 

[Kwiz]

I thought this was going to be a thread for a new category of jokes that start with "you know a drug rep just visited when..."

Probably could have some funny ones about back in the day when reps used to drop off the most random items.

For ex, you know a drug rep just visited when...you look up to see what time you walked in and you get blinded by the reflection of your stores shiny new Protonix(R) clock

 

[SHC1984]

...he orders Silenor 6mg PO qHS. What the heck is Silenor? OMG, it's freakin doxepin! Calls the doc up and rec'd generic 10mg cap, cha ching, saved $515 off this month's budget in <5 minutes. Take that you drug rep!

Seriously, doctors are smart people, they should have just laughed in the drug rep's face on lame stuff like this.

If the patient has insurance and isn't paying cash why does it matter?

 

[Ackj]

If the patient has insurance and isn't paying cash why does it matter?

Somebody has to pay for it. If the insurance pays for that, it's money out of the cash pool that goes toward all the benefits of every member. This means everyone else's copay or premiums will rise in order to absorb that. So sure, it might be "free" or "cheap" for that one patient, but society as a whole is paying for the junk.
Also, xiphoid does inpatient and most likely does not have that oddball in stock. It's expensive to stock something like that, and heaven forbid something happens to the patient and they don't use it, so you're stuck with it. We actually had a patient with this exact medication who decided not to pick it up, and now it sits on our shelf.

 

[PumpkinSmasher]

If the patient has insurance and isn't paying cash why does it matter?

Mindset like this is a contributing factor to our current healthcare system issues.👎 Flat out disgusting.

 

[rph3664]

Not too long ago, Covera HS was in thing for PCPs/GPs to prescribe...because you really have to be careful of that early morning MI.

Cardiologists seemed to know better and rarely wrote for it; health plans and PBMs squashed it to non-formulary.

I remember when Covera HS came out to much fanfare, and then sort of fizzled out like so many other "next best thing" reformulations before and since. It was not long after I graduated, either - in 1994.

 

[rxlea]

Mindset like this is a contributing factor to our current healthcare system issues.👎 Flat out disgusting.

Hopefully she just marries a rich husband and goes into mail order.

 

[Ackj]

Mindset like this is a contributing factor to our current healthcare system issues.👎 Flat out disgusting.

I'd give her the benefit of the doubt and say it's ignorance rather than a poor mindset. Although it definitely is a contributing factor to the healthcare costs, our rigorous drug approval process is incredibly costly as well. Drug companies need to do something to secure revenue until they develop the next new major medication class. Putting up a few billion in research for a failed drug would bankrupt a company without some other "inventions" in their portfolio.

 

[schamj01]

I got no problem with trying new drugs that are novel or improved. I recently got Nucynta for the same doc (must have been another drug rep) because a literature search showed it had merit for select patients.

What's really lame are the pharmaceutical company shenanigans like repacking the same old drug that has been used off-label, get the FDA to approve the indication, and then charge 100x more for it.

I NEVER saw prescriptions for Nucynta before I moved for school. Now there's a doc who writes for it all the time. Always includes those $25 coupons for it too.

 

[xiphoid2010]

I NEVER saw prescriptions for Nucynta before I moved for school. Now there's a doc who writes for it all the time. Always includes those $25 coupons for it too.

On paper, it's not a bad drug, but is about 10X more expensive than traditional opioids. It should be generally reserved as a second line option.

For me, the key advantage it had over opioids were (1) it has significantly better N/V and few other GI side effects, and (2) it is less likely to cause euphoria since it works kinda like a souped up tramadol, making it possibly a better option for patients with higher substance abuse risk.

The funny thing is, after I got Nucynta for that doc the patient begged to be switched back to Norco after just a few doses. I'm guess she didn't like the advantage #2. Now it's probably going to sit there until it expires.

 

[BidingMyTime]

If the patient has insurance and isn't paying cash why does it matter?

Because 99% of patients insurance won't pay for it. In retail, the claim will reject outright and require a PA (which will be denied.) In hospital, reimbursement is going to be a flat-fee based on diagnosis, and the reimbursement will not cover. No insurance is going to pay for a fancy brand drug which has been available for years as an effective generic. Be it Silenor (a new one I learned today), Oracea (we get this one all the time, one would think the doctor would get tired of us calling to change it), Triaderm or whatever.

 

[snopharm]

.

 

[Its Z]

...he orders Silenor 6mg PO qHS. What the heck is Silenor? OMG, it's freakin doxepin! Calls the doc up and rec'd generic 10mg cap, cha ching, saved $515 off this month's budget in <5 minutes. Take that you drug rep!

Seriously, doctors are smart people, they should have just laughed in the drug rep's face on lame stuff like this.

You didnt save $515 or lower the cost compared to your budget. This is an example of cost avoidance which is considered soft dollar.

 

[Its Z]

You dont want a bazillion auto-sub policy. I will push one though p&t and MEC if something happens frequent enough/the cost saving is major.

Talking about that, I am prepping one, removing doribax and auto-sub merrem. But the cost saving from it is really going to come from the alternative dosing policy. Currently debating 500mg q6h vs. 500mg q8h extended infusion, with couple of exceptions. Pros and cons to both, but either way it will save a bundle vs. the old 1 gm q8h.

Yes you do want bazillion auto sub to keep the cost and inventory down. Then if not already, you can build a streamlined formulary onto CPOE.

As far as dori to mero conversion, thats a true cost reduction since youre already spending money on dori. Dori is about 60 to 75 bucks per day and equivalent mero cost is about 45 per day depending on your gpo. So I dont know why you dont think its a significant cost saving.

Go back and look at extended infusion with lower merrem dosing studies done by david nicolau starting from early 2000s through 2007. the 2007 article is actually in british CID. He wont admit it but the lower dosing extended infusion screwed up their pseudomonas resistance rate. I would stay away.

 

[Its Z]

You and I are both pompous and obnoxious. The difference is I know I am. And when I spew crap, I tried to be educational and I typically know what Im talking about. You just got this little Dop Gig 2 months ago. You have ways to go.

 

[xiphoid2010]

You didnt save $515 or lower the cost compared to your budget. This is an example of cost avoidance which is considered soft dollar.

If the drug was ordered, which another pharmacist may do, it would have been $520 pharmacy budget down the tube. But I understand that it is cost avoidance.

But please explain soft dollar. I usually associate that term with trading on wall street.

 

[Its Z]

If the patient has insurance and isn't paying cash why does it matter?

Because this is inpatient and inpatient drug may be itemized billed but the reimbursement is based on DRG. Basically inpatient drug revenue isnt real except for a very few premium insurance plan who reimburses a fraction of the charge.

 

[Its Z]

If the drug was ordered, which another pharmacist may do, it would have been $520 pharmacy budget down the tube. But I understand that it is cost avoidance.

But please explain soft dollar. I usually associate that term with trading on wall street.

Prevention of adr to potentially prevent cost is soft dollar. Changing zyvox to vanco o converting brand to generic or reducing staffing to lower salary cost are hard dollars. Smart admin doesnt put a whole lot of weight on soft dollar avoidance.

 

[Its Z]

If the drug was ordered, which another pharmacist may do, it would have been $520 pharmacy budget down the tube. But I understand that it is cost avoidance.

But please explain soft dollar. I usually associate that term with trading on wall street.

How can the other pharmacist order this drug when its not even on the formulary?

 

[xiphoid2010]

Yes you do want bazillion auto sub to keep the cost and inventory down. Then if not already, you can build a streamlined formulary onto CPOE.

I agree in a pharmacy driven world, yes. But auto-sub policies have rare objectors. While each is likely to pass, I am thinking that pushing multiple through constantly is going to build up resistance down the long term. I have pushed through about 5 since coming onboard, with many more that I would like to do, but I'm biding some time, go from the highest saving ones first. CPOE? we still using quill to write order over here. LOL

As far as dori to mero conversion, thats a true cost reduction since youre already spending money on dori. Dori is about 60 to 75 bucks per day and equivalent mero cost is about 45 per day depending on your gpo. So I dont know why you dont think its a significant cost saving.

Our GPO pricing is $17/vial for Dori 500, and about the same for Mero 1 gm. There is no significant saving there. The saving comes when we go to alternative dosing with the mero since that has data to back up its use.

Go back and look at extended infusion with lower merrem dosing studies done by david nicolau starting from early 2000s through 2007. the 2007 article is actually in british CID. He wont admit it but the lower dosing extended infusion screwed up their pseudomonas resistance rate. I would stay away.

Thanks for the heads up. The Q8H EI was being adopted by my old preceptor's hospitals. After I pushed through Zosyn EI infusion last year, I suspect nursing this time will be pushing for the q6h non EI dosing this time. 😀

 

[xiphoid2010]

How can the other pharmacist order this drug when its not even on the formulary?

My pharmacist can order non-fo drugs. This system was in place before I came on-board.

 

[xiphoid2010]

You and I are both pompous and obnoxious. The difference is I know I am. And when I spew crap, I tried to be educational and I typically know what Im talking about. You just got this little Dop Gig 2 months ago. You have ways to go.

No argument there. Learning as I go.

 

[Its Z]

My pharmacist can order non-fo drugs. This system was in place before I came on-board.

You need to fix that **** right away unless the non-formulary drug is a life saving drug.
If anything, there should be a conditional approval of non formulary drug by the PT chair, admin, and DOP before it can be used.

 

[Its Z]

You made me look up dori pricing. I see it's come down to $17+ per dose. But so has meropenem. It's $11 per dose.

Don't tie up IV lines with EI crap. And if it's G- MDRO, you need a higher dosing anyways. Just don't use penems unless it's necessary and if it's an infection you can treat with EI, then there probably are other more cost effective alternatives.

 

[xiphoid2010]

Your GPO got some good pricing on mero. Ours is ~$375/case of 25x1gm, and dori ~$170 per 10x 500mg. The draft auto-sub right now has exceptions for meningitis and MIC of 4.

Another reason I want to get away from Dori is the recent VAP trial comparing it primaxin, that was stopped early due to bad outcomes in the dori group (even though the trial itself had several flaws).

 

[xiphoid2010]

You need to fix that **** right away unless the non-formulary drug is a life saving drug.
If anything, there should be a conditional approval of non formulary drug by the PT chair, admin, and DOP before it can be used.

I need to look into how to make that work. My place is small and the force is strong with the physicians. Coming from the VA, there are lots of best practices that's missing here, but as you so pointed out, a new DOP stepping on peoples toes right after coming on board might not be the best initial approach.

 

[SHC1984]

Somebody has to pay for it. If the insurance pays for that, it's money out of the cash pool that goes toward all the benefits of every member. This means everyone else's copay or premiums will rise in order to absorb that. So sure, it might be "free" or "cheap" for that one patient, but society as a whole is paying for the junk.
Also, xiphoid does inpatient and most likely does not have that oddball in stock. It's expensive to stock something like that, and heaven forbid something happens to the patient and they don't use it, so you're stuck with it. We actually had a patient with this exact medication who decided not to pick it up, and now it sits on our shelf.

Mindset like this is a contributing factor to our current healthcare system issues.👎 Flat out disgusting.

Hopefully she just marries a rich husband and goes into mail order.

Because 99% of patients insurance won't pay for it. In retail, the claim will reject outright and require a PA (which will be denied.) In hospital, reimbursement is going to be a flat-fee based on diagnosis, and the reimbursement will not cover. No insurance is going to pay for a fancy brand drug which has been available for years as an effective generic. Be it Silenor (a new one I learned today), Oracea (we get this one all the time, one would think the doctor would get tired of us calling to change it), Triaderm or whatever.

Because most insurance companies will require a PAR, for a brand "new" expensive med. This wastes everyone's time, most of all the patient, and delays the med getting to the patient.

My bad folks! I wasn't thinking of it like that! haha....

I almost became a drug rep before my parents force me to go into pharmacy school...so I didn't think it was such a bad job to warrant all these negative responses.

Lea, I am looking into Nuclear pharmacy, but a work at home mail order job would be just as good. I am semi dating this new guy that goes to medical school and wants to be a neurosurgeon...he is 4 years younger than me though...so not sure how that will work out. LOL...

 

[SHC1984]

Because this is inpatient and inpatient drug may be itemized billed but the reimbursement is based on DRG. Basically inpatient drug revenue isnt real except for a very few premium insurance plan who reimburses a fraction of the charge.

I have no idea what this means. What is itemized billed? what do you mean the drug revenue isn't real?

Explain please. 🙂

So overall you prefer what drug and WHY?

 

[Ackj]

I have no idea what this means. What is itemized billed? what do you mean the drug revenue isn't real?

DRG is a diagnosis-related group. So it means that the insurance will pay X amount for Y condition. For a simple (fake numbers) example, let's say they'll pay you $1000 for somebody who has pneumonia. That $1000 is all you're going to get, so if you use the $800 antibiotic instead of the $200 one, that's your loss. It's not like outpatient where you tell the insurance "we filled this drug" and they pay you for that particular drug. Insurance gives a flat rate for the admission, regardless of which drugs they end up getting.

 

[Ackj]

I almost became a drug rep before my parents force me to go into pharmacy school...so I didn't think it was such a bad job to warrant all these negative responses.

I work with a pharmacist who was a former drug rep. He made some good money during his run, and still has a great relationship with many prescribers as a result, but there were lots of great new innovations back then. However, he says he's glad to be out of it with all of the pressure to meet goals and meet a certain number of prescribers per day. Most of the docs realize that these "new" drugs that are actually old generics aren't worthwhile and won't write for them, so it's very hard to meet your goal. Plus you can't mention anything off-label, you are pretty much stuck to reading them the package insert now. More and more hospitals have a "no-solicitation" policy that you can't talk to any of the docs, so that cuts off many potential prescribers right there too.

Although the rumor is that you're a hottie, so it probably could have worked out well for you.

 

[xiphoid2010]

Although the rumor is that you're a hottie, so it probably could have worked out well for you.

lol, one of the technician said the old DOP used to send the techs to check it out first.

Anyway, now we only allow by appointments, so do several places I know of.

 

[SHC1984]

DRG is a diagnosis-related group. So it means that the insurance will pay X amount for Y condition. For a simple (fake numbers) example, let's say they'll pay you $1000 for somebody who has pneumonia. That $1000 is all you're going to get, so if you use the $800 antibiotic instead of the $200 one, that's your loss. It's not like outpatient where you tell the insurance "we filled this drug" and they pay you for that particular drug. Insurance gives a flat rate for the admission, regardless of which drugs they end up getting.

If some insurances don't pay enough for the hospital or the pharmacy to make a good profit then why accept it? I mean if all the places don't accept that insurance than they will be force to pay out more right? I know Walgreens stop accepting insurances that pay out little money. Why don't every other place adopt to that?

I work with a pharmacist who was a former drug rep. He made some good money during his run, and still has a great relationship with many prescribers as a result, but there were lots of great new innovations back then. However, he says he's glad to be out of it with all of the pressure to meet goals and meet a certain number of prescribers per day. Most of the docs realize that these "new" drugs that are actually old generics aren't worthwhile and won't write for them, so it's very hard to meet your goal. Plus you can't mention anything off-label, you are pretty much stuck to reading them the package insert now. More and more hospitals have a "no-solicitation" policy that you can't talk to any of the docs, so that cuts off many potential prescribers right there too.

Although the rumor is that you're a hottie, so it probably could have worked out well for you.

I only wanted to do that b/c I do NOT want to go to school anymore. haha...I am not getting any younger and Drug Reps make six figures just without the extra 4 year degree. That's why I wanted to do it. I heard if you are very good you can make even more. But with this economy I am sure it's getting much harder. Any jobs that pays six figures without any schooling I am interested in.

 

[Ackj]

If some insurances don't pay enough for the hospital or the pharmacy to make a good profit then why accept it? I mean if all the places don't accept that insurance than they will be force to pay out more right? I know Walgreens stop accepting insurances that pay out little money. Why don't every other place adopt to that?

It's a little bit harder for a hospital to do it than Walgreens. Their patients could walk across the street to CVS to get it filled. When you've got a major MI and the ambulance drops you off....

And it's not that they aren't paying enough, it's just that you want to maximize the money you are getting. If you can treat the patient successfully for less, then you keep the change. So why waste the potential profit on a super expensive drug? Kind of like when your parents would give you money for books, but you buy them cheaper online and go out with the remaining cash. (I never did this, but some classmates did freshman year ).

 

[BidingMyTime]

If some insurances don't pay enough for the hospital or the pharmacy to make a good profit then why accept it? I mean if all the places don't accept that insurance than they will be force to pay out more right? I know Walgreens stop accepting insurances that pay out little money. Why don't every other place adopt to that?

Well, there are some different issues here.

Some hospitals do refuse plans. In fact, most HMO's are contracted which specific hospitals that their insurees must use. However, most hospitals are "non-profit", which means legally they must treat everyone who comes on in. And they can't treat people differently. So even if Ins A will pay for Overpriced Drug B, the hospital doesn't want Overpriced Drug B on formulary, because they will have to use it on uninsured patient's as well...with no benefit.

Realistically, most insurance plans are not going to pay for Overpriced Drug B when in 99.999999% of people, Regularly Price Drug A will work equally well--it's not that the plans are not reimbursing adequately for any particular diagnosis, its that the reimbursement cost for diagnosis is based on several factors most notably what is a reasonable cost to adequately treat this diagnosis. The reimbursement is generally adequate to treat patients--it's only not adequate when the pharmacy is dispensing Overpriced Drug B.

Another issue is rural hospitals....they are financially strapped as it is, and can't really afford not to accept any plans, especially since they have to treat anyone who comes in their doors anyway. They can not bargain, the way hospitals in a urban area can bargain.

 

[xiphoid2010]

Like few mentioned already. Hospitals are paid a pot of money depending on the patient's DRG. If you spend less than that to treat, it's profit; if you spend more, you lose money. I think financial word for this method of payment is called "capitation". Some private insurance do rock. We had 2 patients with Cigna, they pay 50% of drug charges. The hospital made more money on these 2 than probably 5-8 medicare patients. Tricare, I was told, is even a bigger gold mine.

But it's pharmacy department's duty is to increase the cost-effective of drug treatments. Docs here used to like Tygacil and Zyvox for MRSA because they are easy to dose, but at a cost of $150-$220 per day. Vanc cost <$10 a day, so it's far more cost effective to have a pharmacist intervene and kinetically dose.

Also, smaller hospitals have less patients to spread the drug cost over. So a few patients on expensive stuff can blows the pharmacy budget out of the water. Heaven help us should a patient on Benefix comes in needing an invasive procedure. 😳

 

[SHC1984]

All very good points. If a hospital has to treat everyone even if they have NO money. Then overall, is a hospital LOSING money every year? What's the net profit of a hospital usually? I mean if the hospital is losing money and isn't making anything I don't see why it would still be open. We do live in a capitalist society. If something doesn't make money, then why bother with it?

 

[Its Z]

All very good points. If a hospital has to treat everyone even if they have NO money. Then overall, is a hospital LOSING money every year? What's the net profit of a hospital usually? I mean if the hospital is losing money and isn't making anything I don't see why it would still be open. We do live in a capitalist society. If something doesn't make money, then why bother with it?

Life and society aren't black and white as you describe. Some hospitals do go out of business. But healthcare financials and profitability is a very complex subject. But at least your schools should have taught you what a DRG is.

Also, hospitals have responsibilties and and commitment to their community to stay open and serve the healthcare needs. They can't simply turn patients away like your local retail pharmacy. We write off losses yet make money where we can. We have resources to take care of indigent patients.

One small hospital can lose money but it can also be a great referral source to a larger sister hospital who can subsidize them.

If you're going to be a healthcare provider... and a responsible one at that, you owe it to yourself to understand more of it instead of just hoping to find a 6 figure salary job.

 

[DedicationNSU11]

What's DOP?

 

[Its Z]

What's DOP?

This is DOPey