Walgreens, Express Scripts and Pharmacy Economics

Much is being made about the spat between Expess Scripts (ESI) and Walgreen's (WAG) over their latest contract. While privately many in the industry appear to be siding with Walgreen's for finally standing up for the profession for reasons listed here, pubically it appears a more even split.

Many decry the terrible burden this is for patients, as they are left to be pushed around by big business when it comes to the management of their health. Others are screaming that it is unfair for the pharmacy employees, as they are merely overworked pawns in this mess.

But with change comes sacrifice, does it not? No one will argue that the business side of pharmacy has been on a dangerous downward spiral for the last 10+ years. So why is it that when an organization is finally starting to stand firm against this spiral, that so many are speaking out against it?

Perhaps we need to simplify what this argument is all about and explain some of the numbers behind it and what they mean.

For a quick overview of the Economics of Pharmacy, check out the associated link. No, it is not college level macroeconomics, but for many who have not directly experienced it, it  does describes what the business environment is like. And, if you'll note, I have a rather accurate prediction in my closing statement.

How pharmacies are paid is quite simple, you are given an amount for the cost of a drug and a "filling" or "service" fee for actually filling the prescription.

Note that the average overhead cost of filling a prescription, before the cost of the drug, is roughly $10. That includes wages, supplies, building expenses and so on. Again, that's $10 for every prescription, irregardless of the cost of the medication.

When it comes to how pharmacies are paid for the cost of the drug is where it becomes tricky. Essentially there is a fictitious average price called the Average Wholesale Price (AWP) that is set as a standard for a drug nationwide. This fictitious price typically is not line with the actual cost, so a lot of times you'll be paid what's called AWP - 10%, which is 90% of the AWP price.

The percentages vary and there are additional systems involved, but this is generally how pharmacy economics function. Now let's run some numbers on a fictional script.

Drug A (Generic)
Drug A AWP: $13.00
Pharmacy Cost: $10.00
Overhead Cost: $10.00
Total Cost: $20.00

PBM Cost Payment: $11.70 (AWP * 0.9 = $13 * 0.9)
PBM Dispensing Fee: $1.50
Total Payment: $13.20

Now you'll notice, due to the AWP, that the pharmacy is actually paid more than the cost of the drug on this prescription. You'll then notice that the pharmacy was only paid $1.50 (15%) of the total $10.00 it costs to dispense this drug.

Believe it or not, this last fact is very common, something which pharmacies have been lashing out against for years now. And, from what I've heard, it is this sticking point which is at the heart of the ESI/WAG stalemate.

Various reports have stated that ESI wanted to decrease their dispensing fee to $0.40, that is 4% of the total cost to fill a prescription.

Now your first question is, "How do pharmacies stay in business if they lose money like this?" With some prescriptions, namely branded drugs, the prices used to calculate cost are somewhat more accurate and they have higher margins due to their higher cost.

The last article I read placed the average cost of a generic drug, for a month supply, at around $10.00 while the average price of a branded drug, for a month supply, is around $80.00. A higher cost allows more wiggle room if you will, and it is these drugs which subsidize the losses on other prescriptions.

The second question then becomes, "Well the fee is already low, you subsidize the cost with other prescriptions and it's only dropping a $1.10, what's the big deal?"

One of the ways in which pharmacy is evolving is that the percentage of generic drugs being used is increasing. The new drug pipeline has dried up considerably in recent years and blockbuster drugs like Lipitor, Prilosec and Claritin probably will not be seen again for quite sometime... if at all.

If you are dispensing fewer and fewer of the name branded products which counteract your losses on other drugs, it becomes increasingly important that you try to mitigate your losses on those other drugs. Pharmacies have been able to survive thus far on the backbone of strong, brand name drugs, but clearly this will not last forever.

Granted, this is a greatly simplified view of what the entire disagreement is all about. One could talk about the effect of the Walmart $4 generic program or government regulation or consumer indifference to the profession itself, but quite simply this is what it boils down to.

You cannot fault Walgreen's for being the first to finally stand up to one of the monster PBMs in this country. The fact of the matter is that Express Scripts needs Walgreen's more than Walgreen's needs Express Scripts.

ESI has no equity with the consumer aside from whatever experience they may have with a help line. Walgreen's has a face, a voice and a place to visit on a daily basis. It is as big of power move by Walgreen's as we may perhaps ever see.

While it's competitors enjoy the new business and take advantage of the situation, I'm sure deep in their corperate offices they are secretly cheering WAGs on as they could be next in the lines of these cuts.

This isn't about lining the pockets of the Walgreen's CEOs or it's investors. This isn't about making a pharmacy a cash cow. It is about taking a stand for what is financially right not only for pharmacy as a profession, but for patients as well. If we want optimal, efficient healthcare, we have to be paid a fair price for this service.

Remember this is not about making more money, this is about saving what little money they are making... if any.

And that, my friends, is why Walgreen's and Express Scripts are in a stand off of historic proportions. Perhaps it's not so bad after all...

Where Is The Passion in Pharmacy?

While struggling through my undergraduate years, what stoked the fires of my soul was pharmacy. I loved every minute of being in one and would do everything I could to absorb myself in the profession. My desk was littered with trade magazines, my computer flooded with pharmacy websites and even this little site here was born out of this fit of passion.

And while time was worn on and I find myself questioning that passion at times, it nonetheless is still flickering. The new fire in my life is my family, but becoming a pharmacist is ingrained in my being after my experiences these past ten years. It is, in many way, what defines me not only for myself, but for many of the people who know me.

So why do I not see this in my classmates? Why do I not see this in my co-workers? Why do I not see this in the majority of pharmacists, 63 and counting, that I have worked with over the years?

Where is that passion in others that drives me each and every day?

It is out there, fleeting as it may be. No matter where I have found myself, I have always had a pharmacist near by who truly cared about the profession. They saw what I saw, yet felt our hands tied in numerous situations.

My classmates seemingly go through the motions of school, jumping when professors say jump and barking when they say bark. Excitement is extruded over cute little informational clinics, the next frat get together, or the idea of an exam being over. We are tested on regurgitating classes of drugs, signs of a disorder and how to dictate a therapy.

Yet there is no passion in these discussions. For many, it's just more school... a means to an ends if you will.

Again, there are those who feel this passion, who want to see change or wish to envision pharmacy as something more than it is right now. Perhaps it is not as surprising that those of us have found each other to varying degrees as we, more or less, stand out within the class.

But we need more passion.

The disillusion in the profession still astounds me. Retail pharmacy is slowly devolving into a profession of puppets, only doing what corporate lays out for them to do no matter their desires. It is almost as if we are living in a George Orwellian 1984 and information is relayed in pharmacy doublespeak.

"Give more flu shots! Push for 90 day supplies! Obtain new patients!.... But we're going to cut your hours by 20%"

"Patient's are of the utmost importance to our business!... But you're going to be understaffed, only allowing you to spend a brief moment, if at all with them."

It is as confounding as it is frustrating. And I can completely understand why those who say they came out of pharmacy school ready to change the world, only to have their hopes and dreams squashed by reality.

My question is why give up? Why let that passion die? Why must so many pharmacists and students be so apathetic?

"Time is the fire in which we burn." - Delmore Schwartz

Above is one of my favorite quotes that I use as a reminder that our time is ultimately limited and that we need not waste it with frivolous activities. Live life and have fun, but do not waste it away merely doing what corporate says.

Find that passion. Fuel it and stoke its fires. Take that extra second with your patient not only to show you care, but to show yourself that you can do what you want.

We do not have to be pawns in a corporate game. We are professionals and we deserve to be treated like so. Stand up for what you believe is right and where you're passion for pharmacy proudly. After all, they can only ignore it for so long...

Be A Proactive Pharmacist

We are all disillusioned in the profession. Considering the majority of individuals do not believe in our national professional organization, I think it is fairly safe to use the term "all."

After talking with APhA for the last month, it is clear that they are aware of the problems we all face. They do, in fact, have some reasonable ideas on how to address them. What they lack though is the solvency to actually act upon them.

One of the most oft repeated phrases is, "Why don't the disillusioned pharmacists show us that they care?" and to be honest it is a valid point. So many have taken such a long drive down the cynicism trail that it's hard to look back.

After all, why put forth a concentrated effort only to have it soundly defeated? I know I feel that way on a regular basis.

But why don't we put for some sort of effort? If not to show to APhA and others what they're missing out, but to give us some pride within our chosen profession.

What I am about to ask is simple... actually it's borderline remedial. We are all extremely busy during our work days, some more than others, but this would take just a minute out of what little free time we do have.

Ask a patient what they think of pharmacy. Ask them if they know what a pharmacist does for them on a daily basis. Ask them if they've ever heard of something called Medication Therapy Management or outline services we could, but cannot currently for financial reasons, provide.

See what they know and see what they want to know. I venture that the answers may surprise you as they certainly have surprised me when I have done this.

As much as the countless pharmacy rants have bound us together over the last few years, perhaps this could do the same. We need hope... the profession needs hope in order for us to continue to succeed.

If you choose to do this, feel free to come back, or E-mail me, and share your response. As cheesy as it sounds, maybe we can make our voices just a little louder and a little more substantial.

It cannot hurt to try now, can it?

The Death of Angry Pharmacy Rants

No, The Angry Pharmacist is not dead... okay well maybe his soul is dead, but his body is still kicking out little amber vials at an inhumane pace.

I started this blog over four years ago partially to centralize my interesting stories from work and partially to partake in the large amount of pharmacy bitching that was present on various websites. I'll never forget the day I first stumbled upon TAP and Drug Monkey's website. The feeling of "You mean I'm not alone?" spurred a smirk as I realized others had the same thoughts as I.

And I loved it.

Finally pharmacists, technicians, students and any one else related to pharmacy had websites where their frustrations could be viewed in colorful and often humorous tones. Many others tried to emulate the original sites, while few truly succeeded. As a profession, a proverbial bitchfest took place day after day on the internet as a means to vent.

And we all loved it.

Four years later though, where are we? The tone of this site has changed dramatically over the years, and something similar is seen on other sites. While the frustration and bitterness is still prevalent through blogs and other outlets like Twitter, it's nowhere near as resonating as it once was. The knowledge that we are not alone is no longer a source of relief, but a part of daily life.

And we all became used to it.

The question becomes, what now? Witty and spiteful posts are often been replaced by more demonstrative and action-oriented posts as shown by Eric, Pharmacist and The Readheaded Pharmacist. One could say that substance is slowly replacing style and it seems as if there are the beginning flickers of a collective voice for the profession. Something APhA, which has been covered numerous times, lacks the ability to do so.

And we all want more.

Perhaps the next step is providing substance towards are frustrations. To focus it into something productive and produce actual change. Many pharmacy bloggers are attempting to do just that and, if the conversations I have had from APhA are accurate, they are beginning to be heard. The time for angry pharmacy rants is ending, being replaced by something which may ultimately be even more fruitful.

And we all will love it.

It is a scary thought how a few late night, profanity laced tirades could propel a, perhaps, legitimate push to change our profession. Evolution often takes a winding and unpredictable path, yet usually leads to a superior result. My hope is that our current trend continues because it holds the promise of yielding true change in our profession, albeit in small amounts at first.

And we will all finally be happy.

A guy can dream after all can't he?

Does APhA Really Represent Pharmacists?

Tonight I was playing with my son with the TV on in the background when a commercial splashed across the screen. Immediately I stopped what I was doing and watched, jaw slightly agape, at what was on the screen.

What was it you may ask? Take a look for yourself:


Beautiful is it not? Even more so when you go to the actual YouTube page and read the purpose of the advertisement. It truly is great to see a professional organization be assertive and stand up for their profession. Clearly the AMA will not sit idly by and wait for change to come to them.

Bravo for that.

Now wouldn't it be great if APhA did the same? Between the health professional organization trifecta of the AMA, APhA and ADA, the APhA is often the silent partner. Whereas the AMA and ADA are very active outside of their practitioners and have a very broad public awareness, few outside of our immediate profession even know what APhA is.

It's one of the topics I have pushed several times on this site in the past and will continue to do so until someone actually listens. Recently I discussed the distressing notion that a business oriented enterprise is, in effect, leading our profession to change for their own selfish reasons.

It is something which has even been brought up in publications like the Wall Street Journal. Interesting how those even within the profession see the massive amount of benefit of the idea I laid out, yet APhA does not seem interested in actually following through with it.

It is this which is the most distressing aspect of pharmacy as a whole. In school and by APhA we are repeatedly told about the "future" of pharmacy, but in reality there does not appear to be a realistic path towards this future. Progress by APhA can be measured by the speed of a sloth, and we run the risk of being bypassed by other health care profession as the system evolves.

For instance let's look over the Strategic Issues on the AMA website which describes who they are and what they are fighting for. It is rather all encompassing while being concise and plotting for the future, wouldn't you agree? It's something even the lay person could read and instantly understand what AMA, and physicians as a whole, stand for.

Now let's look over what APhA has listed as their Advocacy Issues. One of the first things you notice is a lack of an adequate summary to the overall goal of the organization. Line by line and link by link they list specific issues, but there is no connection between the issues and what they mean for pharmacy. The AMA does a spectacular job of presenting their main goals and then diving into the specifics. Here, the APhA merely presents the specifics without any cross-linking to form a cohesive idea. In the end, the problem lies not so much with the issues themselves, but more with how they are presented.

Clearly the AMA's website is focused towards both their providers and their patients whereas APhA's website is tailored to its providers. There is already a disconnect of perception between pharmacists and their patients, and this does nothing but further that divide. If anything, the APhA website continues to make it's self inaccessible to the patients they so often tout as the focus of their work.

Why is this? Why is it the organization, which is financed partially through the dues of pharmacists, seems to ignore this crucial ingredient to the long term success of the profession? Why is it that pharmacists across the country feel like they have no voice?

There was no immediate response to the disparaging remarks by the CEO of Medco from APhA. For those unfamiliar with the situation, this link provides a good summary. How is it that our so-called voice of the profession remains eerily silent while one of the most powerful individuals in health care obtusely insults our profession?

What are those dues good for then? Several times it has been reaffirmed that the APhA can only reflect the views of those members who participate, and pay, through their membership. Granted I see the logic in this, by why is membership required to represent pharmacists as a whole? Why is it that none of the 70+ pharmacists I have worked with over the last ten years are active with APhA? Why is it that rarely do you find a community pharmacist, who just happen to make up the largest constituents of the profession, that considers the APhA worthwhile?

Because they have no faith in it. APhA is viewed as a lion with no teeth and no roar. Why devote time to something which is ultimately fruitless? As pharmacists are pushed around year after year with little light at the end of the tunnel, of course they become disillusioned. Who wouldn't?

So why doesn't APhA throw up a hail mary and start to regain the trust of the pharmacists it represents? Why doesn't APhA consider educating patients on who they are to overcome the biggest obstacle the profession faces, a lack of understanding of who and what a pharmacist is. Why doesn't APhA maintain a daily, strong active voice for the profession which can readily respond to comments from individuals such as David Snow?

Why doesn't APhA model itself after the AMA and actually represent the profession?

Give me a reason to want to be a member of APhA. Give me a reason to want to be extraordinary proactive within the profession. Give me a reason to stand up for what pharmacy stands for. Give me a reason to have faith in APhA.

Is that too much to ask?

Wait, Is That Walgreen's Leading The Way?

Past writings have been evident in showing that I greatly disagree with how Walgreen's conducts their business in the profession. With firsthand experience, it is quite obvious that patient care is not necessarily their primary focus. Clearly I am not alone in this feeling as it is often perpetuated by vast number of other individuals within the profession.

Then how is it that, at this very moment, the pharmacy organization that is finally standing up for, what can best be termed, the unalienable rights of pharmacy is Walgreen's?

Who is challenging one of the largest PBMs in this country and their ridiculous reimbursement rates?

Who is seeking to educate the public as to what a pharmacist truly does in the retail setting?

It's not APhA. It's not the various pharmacy schools around the country. It's Walgreen's of all people.

Actually it speaks volumes that an organization who's ultimate goal is really to increase their revenue is taking this stand rather than the professional organization that is supposed to represent us.  Walgreen's is not attempting to be the torch bearer for the profession, they is just a byproduct to increase their own market share.

There is some irony in that due to Walgreen's inherent greed, they are inadvertently pushing forward a movement that could actually change the profession. The spat with Express Scripts will invariably continue to grow more ugly as they both stare each other down like two bullies on a playground. It's about damn time someone stared them down though... even if it is another bully.

Walgreen's has also been focusing on an advertising campaign regarding their ten point checklist for patient's safety. It may seem trivial to us, but when you consider many people believe a pharmacist merely puts pills in a bottle, this may help to show that we are actually a dispensary of knowledge.

I have been saying for a long time that the profession needs to step up and show the public what it is we are doing. Not only to better facilitate understanding of the profession, but to reveal how much more integrated we can be in the health care system. We can't do it on our own, that has become blatantly obvious, so why do we not have our patients become involved?

And Walgreen's is attempting to accomplish it in their own battles. It really is perplexing as it is intriguing and if the outcome is successful it may prove to be a blueprint for future change.

Who would have thought that Walgreen's would be the first one to take the first step on a national scale? Wonder if APhA is even paying attention...

Health Literacy and Increasing Patient's Decision Making

Health literacy has been a buzz word in health care for several years now. It is an obvious idea when one thinks about it, but may not be overly apparent. Often we take our intrinsic knowledge for granted, and do not consider that a patient may not have basic reading skills yet alone basic science knowledge.

Because of this in class we talk about open ended questions, talk-back guidelines and reading level of materials. All very valid points, but they all underline a common theme. There is way too much unfiltered information out there for patients now.

Think about it, with the internet and sites like Google, the average patient has ready access to nearly the same medical material that health professionals have. This post does not even consider the large amount of misinformation present. I'm more concerned with the sheer amount of correct and pertinent information related to a patient's health.

Think about it, what if you had immediate access to, say, the building plans of your workplace.  The next day you come in and talk to the owner telling them you think this wall should be moved back another five feet or so to give us more room. In looking at the plans, you say it doesn't appear to be doing anything other than partitioning the floor space.

You know what would happen? The owner would laugh his ass off and walk away as you unknowingly want to move a load bearing structure.

Yet this is what we are forced to deal with in health care each day. Patients log on to WebMD or watch Dr. Phil, are presented with information that they do not have the neccessary background to fully understand. They then take this information, come to us and decide to make decisions about their health care without considering our own expertise.

At best it is ludicrous. At worst it is deadly.

I know, I know, you are all screaming. "But a patient has a right to know this information and participate in the management of their health!" And this is true... to a point.

Consider when the negative press about Avandia came to light. One particular patient of ours immediately stopped taking to the medication due to fear of "heart problems." Never mind the fact that the liklihood of this problem was not all that great, we cry wolf far too much in protocols now but that's another discussion, she did not want to die from a heart attack.

The pharmacist looked her straight in the eye and said, "Well you can possibly die from a heart attack or for sure die from diabetes. Your call."

Good for him.

As much as we do not wish to think of our profession in this way, pharmacy is really the management of poisons for positive health purposes. There are side effect whether we like them or not almost solely for this reason.

Many people simply do not understand this part. Life is full of risks, you speed on the freeway to make an appointment or start smoking to look cool with your friends. But when a drug can benefit a patient, but they don't want to take it due to a minor chance of a severe reaction that's okay?


Solutions to this problem can be insanely simple. For instance, when we hand out drug monographs, or when they are posted online, side effects are often listed under categories like 'common' or 'severe'. Dizziness is often listed in the same breath as heart palpitations... but does that mean that the probablity of both are equal? Actually, how often do these side effects occur?

As pharmacists, we know these answers. Patients do not.

So why not add odds of occurrences to all side effect listing? Or perhaps list them in the order of occurrence? I'm sure a few more patients will panic by seeing the exact numbers, but I'm sure many more will have their minds put at ease when they see how rare these 'common' side effects are.

A simple change like that mitigates one of the problems with health literacy and compliance. We have made information a little more digestible and give them a stronger base to make a decision about their health.

We talk about white space and reading level, but not how to relate the information to patients. Honestly, that should be the primary goal of health literacy. It doesn't matter if the material is at a fifth grade level if there is no way for the patient to relate the information in order to make a decision.

And that's ultimately what this is all about, making sure the patient is properly informed so they can make decisions about them selves. We cannot rid the world of WebMD or Oprah, as much as we may want to try, but we can certainly organize the information we give out in a better manner.

Seems simple enough, right?

Realistic Professionalism in Health Care Practice

Inspired by the following post over at 33 charts

Barely an hour into the first day of orientation for pharmacy school we were given the first, of what would be many, lectures on professionalism. We were told how our daily actions, both during and after work/school, would reflect both the image of the school and of the profession. Due to this, we were to maintain professional decorum at all times.

There was also some insinuation that our actions outside of school could be used as a reason for dismissal.

Think about it though, how realistic is it to expect an individual to maintain professional standards at every waking moment? Am I not allowed to see movies with an R-rating in case a patient sees that I may be viewing something inappropriate? Am I not allowed to consume a beer at a restaurant for fear of a patient judging me?

Where precisely is the line?

For whatever reason, too many people today expect perfection. In the mind of the public, there can be absolutely no errors in dispensing or prescribing or diagnosing without an immense amount of retribution. Life is, of course, immensely precious and people feel wronged when something goes wrong. So-called 'News' shows such as Dateline NBC feed off this fact and help propagate the incessant need for perfection.

However as Alexander Pope once said, "To Err is to be human." We are not machines designed for perfection, we are human beings. We have faults, we make mistakes even though we may strive to mitigate them as much as possible. It's one of the reasons why I repeatedly say here that failure is our greatest strength. Perfection is a wondrous illusion, namely because of the impracticality of it.

Humans, well most humans, cannot restrain their emotions every hour of every day behind a professional facade. In fact, it has been shown in numerous studies that bottling up one's emotions has negative consequences. Health care professionals have one of the most mentally taxing daily jobs, yet we are all expected to maintain professional composure at all times.

Due to this, many choose to vent their frustrations not only for their own mental sanity, but to be able to continue to effectively practice. We all have to let that facade crumble at some point or another, and the majority choose to do so outside of the public realm. Whether it is through a blog, Twitter or even a friend, it is where we are able to let our guard down and shed our concerns, fears and worries.

The evolution of devices like blogs and Twitter may prove to be one of the most beneficial outlets for health professionals in their history. It now only spurs new and creative ideas, but let's professionals bond across state and even national boundaries if only to reassure all that they are not alone in your frustrations. Pharmacy blogs like Your Pharmacist May Hate You and The Angry Pharmacist have quite literally helped to relieve the immense amount of stress felt in pharmacies across the country.

For those of us who may be shy when discussing our most personal problems, professional or otherwise, the fact these devices exist is a godsend.

While those popular blogs exist as a source of venting for the profession, it has lead to the creation of other blogs with slightly different focuses such as Eric, RPh and The Redheaded Pharmacist that exist to help better the profession. And this example is just describing the pharmacy blogosphere, not even considering the countless medical blogs in existence.

Yes, some of these blogs and Twitter accounts are crass, using language that would never be used in an actual professional setting. Yet they speak more truth than any professional document you may see coming out of organizations like APhA or AMA.

Why is this?

Because professionalism is self-limiting in that we are all expected to maintain the same methodologies and persona to standardize patient care. In itself, there is nothing wrong with this, but outside of a professional setting how else are we to spur innovation? How are we to explore the good, and bad, of our profession? How else are we to relieve the stress we all feel and actually enjoy life?

We all carefully consider federal and state laws, often artfully crafting responses to ensure the innocent are protected. Every work place has similar gossip-style discussions, and yet similar health care professional discussions are draped in anonymity in comparison. This is a fact even more impressive when considering the amount of venting we all do.

And venting is just that, an outpouring of frustration. What is said during this time should not be construed as a representative of who they are as a person and a professional. The majority of the time if someone stubs their big toe, their first reaction is to spout off a slew of words that would make a sailor blush. Does this mean that we should judge their response and formulate that they are crass and unprofessional?

Of course not.

Expectations are a wonderful device when used properly, but only when they are based in reality. Today the expectations for not only health care professionals, but for individuals as a whole are unrealistically high. Before you decry what and how they say something, consider the benefits they earn from doing so.

Would you rather have a practitioner who is constantly uptight, concerned with ensuring that they abide by all expectations and standards while they treat you? Or would you rather have the practitioner who is able to release their frustrations outside of work and remains relaxed and clear headed?

Before you judge and before you point fingers remember that you are not speaking about a device spouting off medical advice, but a person with a personality and emotions. They have the same needs and desires as anyone else in the world.

If anything it's a good thing others can see these frustrations under the premise that they realize we are not as infallible as they assume us to be. Because of they see that we are not infallible perhaps, just perhaps, they will no longer operate under the guise of perfection.

One can dream, can they not?

I Have A Question… A Lesson for the Profession

It is not very often that my mind is blown while working a pharmacy. After doing this for as long as I have, even the unexpected, to a certain degree, has become expected.

So yesterday when a patient turned to me and said as they were leaving, “I have a question before I go…” I thought little of it. The cynic me expect some inane question devoid of common sense, as typically that is the question you receive in this stage of a pharmacy visit.

Instead what followed damn near caused my jaw to hit the pharmacy floor.

“I was reading up on health care legislation and kept coming across something called therapy services by pharmacists and how helpful it was for the patient. Wouldn’t it make sense for you guys to help out with my drug management instead of just my doctor?”

After pinching myself and realizing that the patient, indeed, had said what she had just said, I quickly began to formulate a concise way to explain what she was talking about.

First, I mentioned that the majority of what she was talking about would be covered under the term MTM. I went over how it works and how it is integrated into current health care. We then glanced over some general cost savings associated with it that could be had, to which she replied,

“So, what you’re saying is that everyone could save money from doing this simply by catching problems before they get worse and making things more efficient? And patient's health could be better? Why aren’t we doing this already?”

I then mentioned some of the studies that had attempt to do this sort of thing, and she wrote down information about The Asheville Project to do a little more research on her own. Lastly, I explained the difficulties we are facing in wide spread implementation of MTM services from the patient, provider and insurer prospective.

It was a conversation which lasted a mere 15 minutes or so, but nonetheless provided a wealth of information for her.

By the end of the conversation, I realized that she was just a typical patient who had stumbled upon what we are all striving for. Inquiring with the normal pharmacy staff, to find out if she was someone with extensive education and/or health care experience, they confirmed that she was none of the above.

And it was the closing statement she made that offered the most telling benefit of our conversation.

“Well pharmacists need to start getting more involved with this. I’m going to talk to someone at my insurer to see why they don’t insist on something like this for everyone because it seems stupid we’re not doing it already.”

The patient gets it. A simple conversation explaining MTMs and the future role of pharmacy, and the patient gets it. And all it took was a little conversation during a slow afternoon in the pharmacy.

Are you listening APhA? This is exactly what I have been saying for the last year. If you want to proliferate the next generation of pharmacy services, don’t go after providers or insurers. Go straight to the source and start educating patients to the benefits of them.

It's a simple supply and demand problem. You can't create something without showing the demand for it. Recently I discussed with the Director of Pharmacy for a, somewhat, rural hospital on how they were implementing MTMs into their patient care for employees. Her, and the hospitals CFO's, idea was to force employees to use MTMs services combined with their own PBM. The plan then was to show the benefits of said program to local employers and attempt to show them the benefits that could be had.

Naturally this will work in their area, due to the small population size. On a larger scale, we need more grand ideas to challenge the status quo.

This little story could prove to be the catalyst that finally gets the proverbial ball moving. If this patient is as interested in MTMs as we are, why aren't we more vocal about it? Why aren't we casually mentioning it to patients who are waiting on slow days? Why aren't we pushing fliers and educational materials to show them what we can accomplish?

Why aren't we standing up for the profession on a daily basis to ensure that we reach our full potential?

APhA, are you listening?

Rite Aid: Cheapening the Profession $5 at a Time

The majority of us are aware of Rite Aid's guarantee to patients that their prescription will be ready in 15 minutes. For the most part, I don't have a problem with that. I give our guarantee to our patients that if you fill your Norco on time, a Spanish speaking Monkey will fly out of my ass and make you a denver omelet.

See, I can promise things too.

Apparently, this wasn't enough. Oh no, in an age where a Dateline special lurks around the corner for a worn down, exhausted pharmacist to make a mistake, Rite Aid decided to kick it up a notch. They decided to offer a $5 gift card if that 15 minute guarantee is not met.

Bravo Rite Aid, bravo. Way to aim yet another shotgun blast to the image of pharmacy.

We live in a world where pharmacy is viewed as a product based business rather than the service it truly is. That's how PBMs reimburse us, that's how the public views us and that's how we are treated on a daily basis. If we are to truly reach the goals laid out by APhA and other organizations, we must truly remedy this fallacy.

But then there is Rite Aid, making sure that for every step forward that we are shoved back another five.

A few weeks ago I questioned why national organization such as APhA did not denounce WAG's creation of Wal-beer. Again, I ask, how can APhA allow such a cheap attempt to attain customers without disparage?

It doesn't so much matter that the 15 minute guarantee is a game of Russian Roulette as it is. Rite Aid just made sure that the barrel is loaded with five bullets instead of just one.

Rarely are we complemented for the work we do in fixing errors by doctors, solving various insurance issues, keep track of interactions or offering simple advice. We are chastised when their doctor takes one day too long to fax back a refill authorization or when the four different C-IIs they drop off take a bit too long to fill.

The public already treats us like we're the bitch of the health care system, there's no need to give them another whip to play with.

People need to start realizing that in pharmacy the customer is not always right. In fact, they are not a customer at all, they are a patient and we are a health care provider. This is not a Jiffy Lube where we'll top off the washer fluid just for the hell of it.

And with ridiculous programs like the one Rite Aid is employing, we'll have a damn hard time trying to convince anyone otherwise.

It's just too bad they can't use their $5 to buy a six pack of Wal-Beer. Oh wait, I think I just gave someone an idea...

To Speak or Not To Speak

This may not surprise most of you, but I apparently already have a reputation among the other classes at my school.

Shocking, I know.

Through the grapevine I have discovered that I have been referred to as the "guy who doesn't take shit from the professors" or "the guy who brings the real world into class."

Kinda cool, wouldn't you think? Except I've noticed a slightly perplexing side effect to this. It seems, almost, as if I'm being blackballed by certain professors.

That big multi-year research project I had mentioned a few months ago? It's suddenly vanished, along with the regular emails from the related professors. In one of my classes, management class, I am regularly ignored when my hand is raised.

It's frustrating.

Which leads me to this question, should I continue to speak up? Should I continue to push the envelope in our classes in order to ensure my fellow classmates, and future pharmacists, have a truthful view of the pharmacy world?

The me of 2-3 years ago would keep at it. Now that I have a wife, a child and a burgeoning career, I wonder if this is the best course of action. This isn't a small, unknown little school and I certainly do not want to create a negative perception of myself as I enter the pharmacy world as a pharmacist.

And since my plans have changed in the hopes of attaining a particular residency, I really do not want to shoot myself in the foot anymore than I have to.

So do I speak up at every inane situation presented, at every fairy-tale story told, at the incorrect information we're fed? Or do I pick and choose my battles and straddle the line of appeasing both sides.

Truly, I do not know. It's part of the reason why I have been "freakishly silent", as someone told me, the last few weeks.

What good is having a voice if it only spouts negativity?

I suppose that is the ultimate question I have been asking myself. And honestly, I do not have an answer.

Improving the Pharmacy Profession… One Wal-Beer At a Time

Walgreen’s bills itself as “The Pharmacy America Trusts.” With that trust comes the responsibility of an honest and ethical management of their patient’s health care. If America trusts them as they suggest, and honestly it’s probably hard to argue otherwise, due to their size they are the public face of pharmacy.

It’s not preferable that one, generic entity represents the varied world of pharmacy, but alas that is what we have to live with.

Imagine the shock pharmacists across the nation had when a little nugget of news appeared, even as it was clearly attempted to be brushed under the rug. That nugget? The creation of Wal-Beer.

We live in a massively evolving health care system in which pharmacists are fighting to rightfully assert themselves as a respected and educated member in modern collaborative practice. For too long we have been either dismissed or ignored, but in the last two decades have seen the profession begin to shred itself of those shackles and become an integral part in the management of a patient’s health.

And it is something to be applauded.

The bigger issue, something which I have touched on in the past, is that while those within the medical profession now readily acknowledge our presence, the public has a complete lack of understanding of our abilities. It is a fact that, at some point, will need to be addressed if we are to reach our full potential.

Now, the public will have Wal-Beer.

How morally and ethically responsible is it for the largest pharmacy chain in this country to create a beer label, with a low-ball price point, in the midst of this change? Pharmacy’s across the nation are refusing to sell cigarettes and alcohol in their pharmacy, yet Walgreen’s has decided to not only ignore this but to instead take it a step farther.

And don’t tell me that it’s okay to sell cigarettes in a pharmacy as the pharmacist can consul a patient on the negative aspects of smoking. The day that truly happens is the day the cigarettes are kept behind the pharmacy counter.

Fat chance of that.

Instead, “The Pharmacy America Trusts” is undermining everything we have fought for these past decades. In class we are preached “Patient Care, Patient Care, Patient Care,” and that our generation of pharmacists will be focused on this for our entire career in new and novel ways.

So how does Wal-Beer fit into that? How is what Walgreen’s doing an attempt to not only further the profession but increase the health of their patient population?

I realize that chain pharmacies are more profit driven than others, but this is a deplorable step even by those standards. Every day we deal with shrinking reimbursements and the lack of an ability to bill for basic services. This is what Walgreen’s should be focusing on and standing up against, not creating its own line of cheap beer.

The better question is, what will organizations like APhA say about it? Will they ignore it? Or will they stand up and denounce the creation Wal-Beer and what it means for the profession? A dare not to be overly dramatic and overstate the importance of doing so… but I’m not sure that would be overly dramatic.

Surely Walgreen’s isn’t the first pharmacy to attempt something of this nature, but as the face of the profession they should be held to a higher standard. If not by the public, then by their employees and the profession itself.

There are bigger fights on the horizon and many will dismiss this as something trivial. It is far, far from trivial however, and represents a dangerous tipping point for the profession. If we wish pharmacy to be properly understood and respected among not only our peers, but the public, we cannot condone this.

Until then, Walgreen’s shouldn’t be the pharmacy America trusts. Hell, they shouldn’t be the pharmacy pharmacists trust. Should they?

I Told You So

From two years ago - http://www.iwanttobeapharmacist.com/2008/04/autism-mmr-vaccine-debate.html

And now it's hit the mass media - http://abcnews.go.com/Health/Autism/link-vaccine-autism-link-fraud-british-medical-journal/story?id=12547823&tqkw=&tqshow=GMA

Hate to say it, but I told ya so...

Because God Said So

I'm man enough to admit not only do I not know everything, but that I continually learn new things almost every day. About a week ago there was a note on a patient's prescription asking if she had new insurance coverage for her birth control prescription.

Her response was that since she worked for a 'really religious' organization they had decided that certain medical treatments defied the will of God and that they would not pay for these items. In this case, one of these 'treatments' was birth control. There were also other 'treatments' that were not allowed, but she didn't really wish to discus them.

And no, the organization was not a church or anything similar to that.

In my mind there is no point to delve into a debate on personal beliefs because we each have our own. Mine is no more superior to yours than yours is to mine. We believe what we believe and leave it at that.

This, however, I do have a problem with. How can you deprive someone, specifically an employee, medical coverage for something because of someone else's belief? How is that fair to others?

Furthermore, how is that deemed acceptable in modern health care? What's to keep the CEO of company from deciding, "Ya know what, I don't believe in warfarin therapy because of my God the Flying Spaghetti Monster and I don't want our health insurance to cover it anymore."

Ridiculous? Sure it is, but the scary thing is that that instance really isn't terribly far from what has happened to this poor woman. She seemed like a well educated and well adjusted married adult woman who simply does not want to have children at this time. And yet she is being punished, in a way, for being responsible.

Sure she could just leave her job, but who is really willing to do that in this economy?

I'm all for expecting and honoring every one's beliefs. But when your beliefs deprive an innocent person medical coverage, then I have a bone to pick with you. Push your beliefs through pamphlets, mass emails, televisions ads, whatever pleases you.

But for the love of God, don't deprive people of their right to health care.

Pun most definately intended.

No One Can Change How You Practice But You

Today a woman in her mid-70s made her way to the out-window of which I was manning. As I brought her name up on the work queue, she started by saying that she recently transferred to us from Walmart due to "those swarmy bastards."

I liked her already.

Since she was a new patient, I went through the usual round of intel gathering to update her file. It was when I arrived at the question regarding insurance that things became interesting.

She initially stated she would be paying cash for her prescriptions. I asked her if she was sure because her prescriptions totaled nearly $900 at the cash price. She was taken aback at first, but reiterated that she was paying the cash price.

After a minute she pointed at one of the scripts and said, "This isn't right, Walmart's been selling this one to me for just $373, not what you have listed there."

Now one of the drawbacks of WAGs system is that you cannot override cash prices, at least from what I've been told. The price we had was, to say the least, ridiculous in it's own right and I wasn't going to make this elderly woman fork over hundreds of dollars extra because of it.

I turned to my pharmacist and said I was going to take her over to our consultation area so I could work with her and see if I can find some way to fix this. He looked a bit perplexed at first, but allowed me to continue on.

I begin to try various filling combos to fix the price. There was changing it to two different prescription strengths, halving tablets, taking more of a smaller dose, etc. I had gotten it knocked down to just a shade over $400, and she was content with that.

It was then that she began fumbling around in her wallet for her credit card when I noticed her Medicare card. And it dawned on me; she has to have Part D coverage and, if she doesn't, she has to have some sort of supplement.

I ask her if she's enrolled in Medicare Part D and she replied yes. Next I ask her why she didn't mention she had any coverage at first and she said it was because she had lost the card several weeks ago so she didn't know how to get us the information. Naturally she was surprised when I said I could look up her information simply by using her Medicare number.

As she hands me her Medicare card she then states, "I don't know how much good this insurance stuff is gonna do me." I ask why and she goes, "Well they don't cover that spendy one right there cause I've been paying cash for it all year. And I'm in the donut hole so Walmart told me it's better to just pay cash for everything."

Are the alarm bells going off in your head? Because they were going off in mind.

First, I explained to her that I would be very surprised if they did not cover the drug in question. It's not an uncommon generic drug and I'm not sure if I've ever seen someone not pay for it since it went generic.

Second, I then explained to her that when you're in the donut hole you don't really pay the 'true cash' price. The price given, if you will, is more of a discounted cash price and is usually less than what WAGs or Walmart can match.

Of course she asked why her Walmart pharmacy had never explained to her, of which I had no answer.

I proceeded to input her Part D information and rebill. Suddenly that almost $400 medication she had been paying for at Walmart was now just $40.

She was shocked. Utterly and completely shocked. By the time I re-ran everything, the total bill was around $280, down from the $900+ originally. She thanked me several times for helping her as she left, while I sat wondering how in the world another pharmacy could be so inept at helping a patient.

Then I remembered that Walmart employs more of a profits before patients policy, similar to what I alluded to in my last post. Their pharmacies are often overworked and understaffed. A corollary to this is they have a tendency to hire 'cheap' techs who may not know as much as they could otherwise.

To make things even more interesting, my pharmacy manager pulled me aside and said he hadn't seen anyone do anything like that here in the eight years he's been working at WAGs. It reminded him of working in his pharmacy back home.

I told him there's no reason you can't practice like that, even in a WAGs-type setting. It's how I decided to practice long ago and where I work won't change that.

Ultimately, I think this is the moral to the entire story. It doesn't matter where you work, what you do on a daily basis or what corporate wants you to do. We still have an opportunity to take some time with our patients to help them.

We choose how we want to practice, no corporate decree can change that. It doesn't matter how busy or how swamped you are, I did this entire exchange during the 5pm rush on a Friday afternoon.

And if I can do it, so can you. All I ask is that you try...

Taking On Walmart: Lawsuit Style

Over the top post title? Perhaps, but hear me out.

Every one within the pharmacy world agrees that Walmart pharmacies are the cancer of the profession. They are mostly detrimental to the profession, to the point that something needs to be done about it.

In the Walmart I recently worked at, my store manager told me the pharmacy is responsible for 4% of the yearly revenue of the store. Think about that, just 4% of the entire store. In the great scheme of things, the total profit brought in by the pharmacy does not have a high priority. What a pharmacy does accomplish, though, is to drive more people into the store. And that's where the problems arise.

It's not difficult to imagine that twenty years from now we will see the final death blow for true small town, rural, independent pharmacies as the four dollar generic program that Walmart began a few years ago. The effects from this program will begin to become more evident as the years wear on (I personally believe it will, or maybe already has, trickle over to the reimbursement side of things). It's a program which is great for consumers, but utterly terrible for pharmacies and pharmacists.

Previously I have covered how we are routinely underpaid by insurers for the services we provide. Here is how Walmart, in its revenue based mindset, gouges the profession using poor, and unethical, business practices.

In the state I am in at the moment, the average cost of a prescription, prior to the addition of the cost of drug, was $10.28 as of 2006. This is the most recent data we have and does not take into effect the legal changes since then which have significantly increased overhead labor costs. If you consider that the most of the drugs listed under the $4 generic program actually cost roughly $1 per 30-day refill, we're looking at a total cost (in this state) of $11.28 per 30-day supply.

Using a bit of simple math, we can see that Walmart is selling these $4 generics at 64.6% below true cost. Sure they're making a "300%" return on the cost of the drug, but we're a service based profession and you cannot quantify cost in that manner.

Here is where the lawsuit would come into effect; there are laws in place to prevent businesses from undercutting competition by ensuring that they cannot price their products and/or services below a price floor, namely the cost of the product/service. It a byproduct of the monopolistic tendencies of big business at the turn of the 20th century and the anti-trust laws that followed.

This is called predatory pricing, and it is usually intended to drive competition out of business. In Walmart's case, they are doing so to drive more consumers into their store and not so much to rid them of competition.

However, one of the key components of predatory pricing is a high market entry barrier. By pricing their prescriptions so low, and under cost, they are in effect presenting a high market entry barrier. It is one thing for a new, or small, pharmacy to be unable to offer all of the insurance plans offered. It is a completely different problem when they cannot come close matching the cash-pricing policy of Walmart.

Under the Sherman Antitrust Act, this is considered monopolistic business practices and is unhealthy for both the market and the consumer. And, at least legally, you could file a class action lawsuit claiming as such.

The thing is, you would lose the lawsuit. Walmart is far too big, far too powerful and with far too many attorneys. Also, it has proven difficult to adequately argue for monopolistic business practices, although I concede we could develop at least a moderately successful argument.

But here's the best part... we wouldn't have to win the lawsuit.

Really what we need is consumer awareness of what is happening within our profession. It's been shown time and time again, especially when it comes to Walmart, that when the public is presented with an injustice they will move on their own to attempt to right it. People like a good deal, but only to a point.

We have the data, we have the facts, we have the manpower, so why not? What's stopping a group of us from standing up and actually doing this? It isn't about increasing pharmacy profits, about maintaining the integrity of one of the most important health care professions in existence. We an argue convincingly that we have been put on a dangerous path and, if it is not righted, in a few years we will be presented with a very serious problem.

Cost/revenue cannot be the sole driving force for the profession, yet Walmart, and to a lesser extent the other large corporations, have decided to take that route. It will continue to harm us, the market and, ultimately, the patients. The last part of that statement is what we have to proclaim most loudly.

Let's rile up the consumers, let them see how big business is harming one of the essential health care services in this country. It can only go up from here, right?

Presenting the 2010 Medicaid Mother of the Year

My work day after Thanksgiving in this new city proved to be vastly different than what I am accustomed to. Whereas I am used to being completely swamped on Black Friday, here the pharmacies are a wasteland. So imagine my surprise when midway through the day I realized I was in the presence of greatness.

I had met the Medicaid Mother of the Year. Shocking, I concede, that she would choose to visit our little pharmacy on this day, but alas here she stood.

Chatting on her iPhone 4, bedazzled of course, with her Coach purse and fancy manicured nails, she presented to prescriptions for her 18 month old son. And she presented her, and her son's, Medicaid card.

One of the prescriptions was written for Amoxil and the other for Orapred, nothing out of the ordinary. As she loudly chatted with one of her baby's daddies, I took the scripts to the counter and began to input them. It was then that I noticed both scripts had the DAW box checked.

Perplexed, I dialed up the urgent care doc who had written the scripts and asked the nurse on call if she could verify the DAW. Often a slip of the finger can slap DAWs on scripts when they are unintended. When the nurse returned to the phone she informed me that it was the patient that had insisted on the DAW and that they were written correctly.

Cute.

We call her to the counter and the pharmacist asks her why she's insisting on the name brand version of these medications. Her reply was that, "Generics don't work that good and she wants the best for her bab-ah."

We both calmly explain that in order to fill each of these prescriptions we would have to order the drug in. The likelihood that a store in our area would have either one of these drugs in stock was negligible. And, since it was a Friday, we informed her the soonest we could get the medication would be Monday morning.

"That's ok," she replies.

Next we inform her that in order for Medicaid to pay for these medications we're going to have to get a prior auth on both drugs. That, in itself, meant that we wouldn't be able to bill the insurance for payment until Wednesday at the absolute earliest.

"I'll just wait, he can tough it out until then, he's a strong lil dude like his daddy. I just want him to get the best meds, I don't want none of that cheap shit."

Let's get her tiara and flowers ready, because this woman just kicked the rest of the competition to the freakin' curb.

Yes, let's deprive your ill child of the medication he needs simply because you have some sort of righteous belief that you deserve the best even though it is those like myself who will pay for it. Never mind your suffering child, hold tight to that notion.

Because when child services show up, it's the only thing you're going to have left.

Am I Too Cynical?

One of the greatest realizations a person can have is that you are not always right. In fact, you're probably wrong more often than you may think.

That statement is the precise reason why I won't enter politics; I'm too open to the ideas of others in place of my own if they are better. I fully concede there are times when I am completely wrong or have an illogical train of thought. I do my best to think things through in a logical manner, devoid of emotional input, but we're human and at times that is simply not possible.

It goes without saying that I probably have more intimate knowledge about the profession of pharmacy than 99% of my classmates right now. I do not state this as an ego-booster (although I have been told that others would disagree), but as a statement of fact.

I think we can agree that most of the material published on the pharmacy blogs, this one included, has an overtly negative tone. Sometimes I justify this as merely being realistic about the profession, an idea which is grounded in some logic. Recently I've been debating if this collection of negativity has clouded not only my judgment, but my attitude.

In more concise terms, I have become too cynical.

All we hear about, or talk about, in this type of medium is the negative. View any major news publication and the stories that receive the most, and most consistent, play are negative in nature. Call it a byproduct of our society if you will, but because of this we have become colluded into viewing the world in negative lights.

For instance we all argue about the adverse effects of mail order pharmacy on the profession and the care of the patient. It's something that has been beaten into my head from various sources over the years so much so that any 'good' news regarding mail order pharmacy is met with a sneer on my face.

Imagine my surprise last week when I went to a presentation and was introduced to a mail order system that actually works. A system which is producing better outcomes than the traditional retail setting. A system which solves the majority of the problems we associate with mail order pharmacy.

I sat, jaw agape, for much of the presentation. "How can this be?" I thought.

Over the years I had grown so use what everyone else had been saying about mail order that I neglected the fact that it could possibly work. Something which I had written off as a death blow to the profession in fact has a very helpful place within it.

In essence, I had not followed my own mantra of being open to the ideas of others.

There is no particular blame to be placed. What is said, for the most part, needs to be said. The context of what is being said, at least in my mind, needs to remain forefront

After all, I don't wanna grow up to be Scrooge. Or do I....

What's a HIPAA violation?

Let's play with a hypothetical example today.

Say you and some classmates are given the assignment of tracking the health of an individual in a retirement community over the course of several months. There is a school website, with greatly restricted access of course, in which you participate in discussions about the overall project and complete assignments.

Then let's say that there is another sub-section of that same site where only you, your group members, and your professors can read what you post.

Now one day you're discussing with your classmates on this site about the next visit and you inadvertently use the first name of the individual you're tracking in the discussion.

Is this considered a HIPAA violation?

I ask because I was told, and corrected, by a professor that it was indeed a violation. For the life of me, I cannot seem to figure out how this would be and said prof has yet to respond to my email.

It's on a non-public webpage so restricted only six people can view it. It is a part of the pharmacy school, which is in turn part of a health care facility. No other relatable information was disclosed in the discussion, merely the slippage of the individual's name.

In all of the HIPAA training I have received over the years, I cannot see how that would be a violation of the law.

Am I missing something here?

Thank God for Advil Congestion Relief

With the winter season quickly approaching, all are in the opening stages of prepping for the onslaught of the winter cold season. With the exception of the occasional sadist, no one in enjoys the sneezing, hacking and congestion the arrives with our yearly cooling.

But wait.... What's this? Could it be a savior for all of our cold symptom woes?!?


Contains Ibuprofen AND Phenylephrine? Genius!

1 Pill Dosing? Spectacular!

And at just $8.98 for 20 tablets it's a steal!

Hooray, the upcoming cold season is already defeated! Let that pesky rhinovirus burn in hell!

Wait a minute... 200 mg of ibuprofen... 10 mg of phenylephrine? How can this be? You could by the separate components for a mere fraction of a cost... but then again why would you to begin with?

With that sort of dosing you might as well just eat the box. Maybe drizzle some Nyquil on it for added effect and flavor.

Oh Pfizer, you never cease to amaze me in how you can squeeze money of the unknowing consumer. Bravo to you and your creative marketing product. Hope you can sleep well at night in your giant mansions.

Congestion free of course.