I think I've finally identfied how a desk job can make me so tired. I spend half the day trying to reason with the government and the other half trying to figure out who is lying to me. :/

With the H1N1 vaccine starting to hit communities, I thought I would share with you the info about preservatives, latex, etc that I collected for the nurses at work in case any of you have concerns.

( Websites for H1N1 and vaccine info )

 

( Table of vaccine manufacturers, injectable/nasal, live/killed, allergen, packaging, preservative, and latex info )

 

 

( Vaccine information sheets (like they give you at the MD's office) )

 

 

( General information about vaccines )
( Links to the prescribing info for the H1N1 vaccines for really gory details )

My two major recommendations remain the same:
1. Don't freak out
2. Wash your hands
to which I will add:
3. Get yourself and your loved ones vaccinated, unless you have contraindications.

I am more than happy to answer questions, either in the comments or privately.

The new H1N1 influenza vaccine is out! States recieved the first doses today or yesterday. The first doses are of the live, nasal variety and are reserved for high-risk populations. The more usual, injectable, killed vaccine will be out in the next month or so. Below are the VISs (vaccine information sheets) for the two forms.

Inactivated Injectable Vaccine
http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-inact-h1n1.pdf’
 
Nasal Live Vaccine
http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-laiv-h1n1.pdf

General information about H1N1 influenza
http://www.cdc.gov/H1N1FLU/

I don't know what possessed me to think that a morning conference was a good idea... Especially at 7:15AM... Especially an hour and a half drive away. :p Ew.

However, the conference promises to be really useful for my practice - antipsychotics in the elderly, refractory depression, anxiety disorders, antiepileptics, and complicated migraine management. Crazy, crazy, crazy, pain/epilepsy, and headaches?they could not have designed a better program for me!

Ok... Next speaker starting...

It's 10:30. I'm already quality done. And LJ apparently hates me. So does the world.

Can I go home now?

Most days, I love my job. It's hard, thankless work, but good work. I know I am making a difference and providing very necessary services...

But some days, it seems that I'm fighting an endless tide of poverty, lack of education, mental illness, and society's inability to show human decency to its least members.

I came home with a fatigue and a headache I just could not shake. I had a lot to get done for WW tonight and thankfully had some help getting it done, but I still need to pack tomorrow and drive out to site. I decided to take the day off from work - I have just too much for the event that still needs prepping and I am just too tired to face the work problems again tomorrow.

Usually, I like Boston Legal and I thought watching a few episodes while working on handwork would be pleasant, but with a running theme of mental illness, drugs, various flavors of love, Alzheimer's, and euthanasia, it did little to lighten the mood.

Anyway. Off to Boscobel tomorrow. Expect a report next week, probably not on Sunday night. :P

 Ugh. The world has gone all stoopid.

Since I came in this morning, I have had to deal with: members burning down their whole apartment complex including all their drugs and prostheses, the file I worked on for half of yesterday is just GONE and irretrievable according to IT, requests for wasteful and/or unnecessary medications, and CMS yelling at me for not submitting a file for which they have not yet released the guidance and which I MUST have submitted and approved by the end of the day. Gah! Nevermind that it is just a fluke I'm here at all - I usually have off on Fridays...

I'm starting to wonder when someone is coming in to shoot me and put me out of my misery.

**********************

EDIT: OK, now I'm just full of unholy rage. Some of our members and their families tend toward the evil, but this just takes the cake. The member - who seems to be a reasonably nice old man - has this marginally-involved evil son who wants to get his hospice-enrolled dad a scooter as a thinly veiled attempt to take the scooter when his dad passes. Thinly veiled as in he has mentioned that he might "have to" use it even when his dad is still alive. Even better? Evil Son wants his actively dying father to sleep downstairs on the couch so he can sleep in the bed upstairs, which, by the way, is next to the only functional bathroom in the house.

I want to go over and throw the son down those stairs. 

I am carefully not looking at the address.

Ugh. For days I've been feeling like someone has been beating me in my sleep, but today has just been extra special on top of the existing blech.

Within 10 minutes of getting to the office, I snagged my hand on *something* and there was a pretty impressive amount of blood for such a tiny wound of mysterious origin.

Lunch was fail. Someone ate my freezie dinner and my back-up lunch can of split pea and ham soup ended up being "hearty bean and ham" instead. Yucky.

So, my coworker and I thought we'd take a little post-lunch walk... I got as far as the sidewalk and tripped over one of the transportation van's "safety lifts." I had been looking at the planes taking off into the bright blue sky and so went sprawling ass over teakettle into the parking lot. Owie. I scraped my palms, skinned my knee, bashed the other shin on a metal part of the ramp and may have slightly dislocated my shoulder - it had been hurting, but when I stretched it, there was a loud pop and it seems to be less angry. Just call me Grace... :/

*sigh*

45 minutes to go... Maybe I'll make it out without permanent damage from my cooshy desk job. :P

I need to have the formulary done by the open of business tomorrow morning, so I'm spending the night sitting in the ambition-sucking chair and agonizing over the minutiae of a 5,000 line Excel document and its multitude of appendices. *sigh*

At least I'm having a Strongbow with my massive drug consumption. ;p

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EDIT: 2:18AM - Done! Now off to have a little crack (read: custard) and then bed.

...but today I had a bit of an issue finding my car. :P I've gotten so used to parking it in the garage, I had a moment of confusion when it wasn't there this morning. I'd just parked it in the driveway, but there was a moment of intense panic about where the hell my car had gotten to...

Once I got to work it was a somewhat better day. I am awaiting the release of the formulary training for 2010. It was supposed to be out last week, but there are some technical glitches. My life will be busy again once it comes out, though, so I am somewhat enjoying the quiet. Once we start the process, it is a lot of hurry up and wait as formulary versions are submitted, reviewed, inevitably rejected, revised, re-submitted, rinse, repeat. :P However, I had a great meeting this afternoon - I love working for a granola-head company - we are encouraged to take walks for excercise, while we are thinking through a problem, or while having small meetings. I went on a walk with my co-worker, one of the medical directors and the NP practice lead for about an hour. It was part fun and part serious, but it was all out in 70 degree sunshine, so it was definitely a win.

Tuesday afternoons I always have an indoor meeting (since several people teleconference for it) that discusses requests for non-covered and high cost items. Today, we had a request for a fire-retardant apron, really an item more like a barber's drape, for a patient who has Huntington's but continues to smoke and so keeps burning herself accidentally. There was some discussion about whether this is a clothing item (not covered), a saftey item (maybe covered), a device that promotes smoking (not covered) or what. Apparently, the patient currently has no desire to quit smoking... I think I broke some of the nurses when I suggested that, if we were going to bend the rules and provide clothing, we may as well have it be clothing to deter smoking - how 'bout a kerosene shirt? :P They were horrified, but that ended the talk of supplying clothing and focused us on recommending smoking cessation as the better option, which was sort of the point anyway. Sometimes, I'm not particularly nice. Effective, but not necessarily nice...

This evening has been marginally productive - mightyjesse and I made a quick visit to Hobby Lobby and the Dollar Store, then to a Chinese buffet, and finally home for some Scotch and sewing to celebrate St Paddy's Day. In all, a good, relaxing day. If I make it to bed at a reasonable hour, it may be a near-perfect evening.

So, there is a Big Bad Pharmacy that had been making use of a loophole in our billing software to overbill us on a few items. They gave us pretty good prices on a lot of other things and they fill closed to 15,000 prescriptions per month for us, so the overbilling wasn't readily detectable (and I'm pretty sure not even intentional, at the local level at least). Buuut... a little here and a little there and eventually I caught on. It sucked like a week of my time last fall, but I put together a massive spreadsheet of these errors over the last few months and then requested that the incorrect claims from the last year be reversed and re-run with the correct pricing.

A few weeks ago, they did the first batch of re-run claims, netting us $12,000. W00t! I was please, my boss was pleased, the VP in charge of the budget was exstatic. $1,000 per month is not a lot in the grand scheme of things, it's really only about seven cents per prescription, but biy does that add up!

Today, I got the report on the second half of the project - $78,000

*boggle*

I earned my keep and that of some other folks as well... Even $6,500 per month is a teeny drop in the bucket of the pharmacy budget (our folks average $500-900/month in prescription drugs alone, depending on the program they are in) but $78 grand is $78 grand and in these tight times, I'm expecting that it will be welcome news.

So... at work I endlessly toil and slave at perfecting the formulary and reducing drug costs. One of my big weapons in controlling the drug budget is the use of generic medications. The FDA encourages the use of generics. Medicaid encourages the use of generics. Medicare encourages the use of generics. But today Medicare rejected my third quarter Part D data... because the generic usage percent was "too high" in one of my programs! Specifically, their computer says that it is "impossible" that I have been so effective as to have pushed the generic usage up to 81% of prescriptions filled. So... "Use generics! Use generics!" they say... and then they say "We can't believe you use that many generics!" :P Oi. My head hurts. And it won't get better - sooner or later they'll review the OTHER program... where the generic usage rate is over 85% ;)

The head hurty is also unlikely to improve considering I have a combo allergic/viral illness thing going on right now - I picked up a cold this weekend and spent the evening cleaning out a closet that, in retrospect, was probably heavily contaminated with cat residue. Owie.

Our help desk department is usually... special. They out did themselves today, however. In "fixing" a problem, they wiped out all the email (ALL the email!) from sometime Friday afternoon until 3PM today. It us apparently unrecoverable >:/


Now I'm trying to remember what all I had come in, which items were critical and how to go about re-obtaining and/or recreating all that information. Splendid.

Well, I've not really posted anything of substance in a fortnight, so here's a general update on Adventures in Eithniland. :)

Thanksgiving weekend I was spectactularly productive. I was in a bit of a funk, but for some reason, that made me more likely to work on the little nagging things that had been on my to-do list forever. Over the long weekend and the days following, I: (sorry, my happy list just won't go behind a cut...)

• Had my car tires changed
• Had windows installed
• Wrapped Christmas presents
• Did the last dribbles of Christmas shopping - now I just have some hings I need to make/finish
• Read a prodigious amount
• Cleaned the basement a little
• Stained the shelves for my curio cabinet and put out my pretty froggie teapots, finally!
• Painted or stained windowsills, bith the new ones and the ones done a year ago
• Sewed curtains for the kitchen - they match the walls!
• Finished some detail work in the laundry room, including fixing the dryer (thanks kumakun!)
• Reorganized my "purse folder" where I keep copies of all my handouts and necessary stationary
• Sewed little "flags" onto the ends of my keys so they are easier to find
• Sewed a pair of pants
• Embroidered some favors and sewed them into favors/bags
• Repaired my winter jacket
• Sewed a scary hood - it looks like I skinned a kitchen green Muppet, but it is Sooooo warm!
• Hung out with a variety of wonderful folks
• Ate entirely too much food

In all, an excellent holiday...

The following week was uber-stressful at work and I was very glad it was another short week. (Essentially, I found another pharmacy billing problem, different in nature and from a different pharmacy than last time, but this time instead of being helpful and interested in correcting the problem, the pharmacy ownder was combative and defensive. I get to meet with him this Thursday about it. Goody. :P) However, since I usually have off on Fridays, the Friday Thanksgiving holiday became a floating holiday for me - with the only catch being that I had to use it sometime in that pay period. Therefore, I took the next Thursday off as well and enjoyed another four day weekend. 

Since the folks at Border Downs had been so welcoming a few weeks ago and been so kind to send me an invite to their Yuletide event, I decided to spend my mini-vacation off in South Dakota. I woke up at a reasonable hour on Thursday and enjoyed a leisurely drive in. The soundtrack was"random radio" where I just hit seek every time the station I was listening too began to fade or annoy me. Consequently, I listened to a strange variety of stuff. Some did not last very long (scary right wing blather) and some was surprisingly infectious (Beyonce's "Single Ladies"). Upon my arrival, we grabbed dinner out (mmm... pierogies) but did not stay up too late since my host was not spoiled like me and had to work on Friday. I, however, had the luxury of being decadent and spent Friday sleeping in, reading, baking bread, writing my letter for the newsletter, and otherwise being only marginally useful. Dinner was rainbow fajitas with friends old and new and a really alarming amount of vodka cranberries. ;) Even with sleeping in on Saturday, I got to the event at a respectable hour and spent a really pleasant day illuminating and geeking on fiber topics with ladies from the Shire, including the ever-cheerful zarhooie. I finished two scroll blanks and even snuck in a nap before helping cenedra_nasio  with a special present for the King. *grin* Feast was a little late, but worth the waiting. Mmmm.... giant chunks of dead cow and a wnderful gooey mass of cheese, bacon, and asparagus. Nummy. The postrevel was fun, but I was pretty beat and ended up drifting off for a bit on the ambition-sucking couch. I did get to see the Dr. Horrible show again, though, and that was worthwhile. I think it was nearly three by the time my carpool headed back to SF, however, and that made the morning somewhat less successful than necessarily desirable. Jara's General Meeting was that night and in order to reliably have made it on time, I would have needed to be on the road by 11AM, noon at the very latest. I am Not a Morning Person (TM) even when I have not been out partying half of the night, so that did not happen. Happily, I know myself well enough that I had warned my lovely Seneschal rezansky, reviewed the items on the agenda, and made the appropriate arrangements. Bad Baroness, I know. :P It was worth it, though, to sleep in again and then enjoy a leisurely lunch with folks, including one of the fellows I had met on Friday night. The drive back was blessedly uneventful and I spent the majority of the ride listening to NPR in its various flavors (SDPR, IPR, MPR, WPR, as the tuner could pick them up). The weather got a little nasty as I was coming into Madison, but I made it home safe and at a reasonable hour.

Yesterday, I had a half day at work and then went to do a demo at the Madison Country Day School. The kidlets were a lot of fun - they were well-to-do 5th and 6th graders in a seriously college prepatory preK-high school, so they had a lot of really good questions and were really very interested in the clothing, even the boys. (I wore my 12th night gown from the year before last, which was perfect since they had just started Henry VIII.)  Unfortunately, pretty much the whole time I was in there, it was raining and freezing on my car. :P There was a solid 1/8 to 1/4 inch of ice covering my car - that was really pretty special to get off... the drive back to work was pretty wild too - halfway back I decided I was just goint to head home - I'd only have had maybe about a half hour to work by the time I got there and the weather was quickly deteriorating. I did some work at home instead - hurray for remote access! Even better, this morning my boss called to tell me we were closed for a snow day, so I have spent the day cleaning, doing some laundry, doing some research, and being slothful. I want to get some work done on some projects for this weekend, however, so I am going to try to see if I have any Thanksgiving leftovers of productivity around here somewhere and get cracking. :)  Here... watch me go... Mighty powers of productivity... yeah...

Work is somehow both kicking my ass and making me look like a rock star this week. :P

Cases in point -

I was asked to head a committee on emergency cell phones for our members who are often in the community, but still need a lifeline-type item. Clearly, this is not drug-related, however, I am apparently the geeky-techie solve-weird-problems go-to girl. (I did find a wonderful low-cost solution BTW... and now know about all the cheap-o cell phone deals on the market...)

The budget guy at first thought the ~1% decrease in drug costs per year must be a mistake (a 5-10% increase is more usual). Then, since we need to "save" money anywhere we can to keep the program budget in the black (it is currently very, very in the red), he wanted to assume a 1% decrease next year too! Eeep! Um... I'll do my best, but I can't promise that!

I have done a series of product analyses that will help us provide better quality dietary supplements to the patients, promote infectious disease control, educate the nurse practitioners, and still save us money in the long run.

Whew! Now, off I go to practice...

I have had a day. :/

Between the usual work yuck, I had some extra-special disasters today. On the work end, our 2009 formulary was rejected with over 50 things to change - and last week they had blackmailed us into signing a document that pretty much says we will make all the changes they ask for. Nevermind that the week before that we got crap for our per member expenses and over-use of certain medications. How can we control cost if they will not allow us to control the formulary or other services? By and large these are people who will make use of every last service and pill they can get their hands on... Granted, a looser formulary means fewer patients, nurses, pharmacists, and doctors yelling at me. Right now I have the definition of a thankless, Sisyphean job.

Then I tried to make an appointment to get a new primary doctor, since mine is leaving. The scheduler brightly informed me that she'd be happy to help me schedule with my MD of choice... What day in the last week of April 2009 would work for me? If I want anyone with any sort of GI/Neurology specialty, it will be even longer than that. I CAN get in to see one of the new MDs in the next couple weeks, but by new I mean just-out-of-residency, not-yet-Board-Certified new. As is no experience with complicated problematic cases new. Add to that that English is not the first language for either of them and they both just came to the US for their residencies about two years ago. Fantastic. I went with the Russian one, since at least I know what pathologies to expect with that and know how to handle them. At this point I'm just hoping I get written off as too much of a complicated mess and get referred to a specialist.

*sigh* I'm crispy, can you tell?




EDIT: OK, I realize I am lucky to have decent health insurance coverage and all that, but it just doesn't seem to be of much use when I have to wait eight months to get a basic appointment with a GP.  :/   So much for the superiority of the for-profit medical world. I can haz socialized medicine now?

In news of my aunt, from my mom via email this morning:


Thank you for all those who offered their thoughts and prayers. I'm not a particularly religious girl, but I do believe in the power of such things.


********************************


On the Jara list, someone asked for assistance sewing a "standard" rapier kit. You know, just a linen shirt and doublet. *grin* Huzzah for the defeat of Evil Trigger! The One True Way of Linen will soon take over the world!


********************************


I got an email from some ladies in Glenn Abhann who are looking to put together a Garb Wars/Golden Seamstress/Griffin's Needle Challenge sort of event and found my webpage/blog. Of course I was more than willing to share the crack and send them the info I had.

They don't have a date yet, but assuming it doesn't conflict badly with something else, anyone interested in a road trip? :)


********************************


Yesterday, at  lunch, I was thinking about life and stuff and suddenly had the undeniable urge to reread Walden. Thanks to my iPhone and Project Gutenberg, 45 seconds later I was.

I <3 my phone. I <3 teh intarwebz.


********************************


This morning I got an email on the NS Hall about an A&S Throw Down to be held March 28, 2009 in the Shire of Trewint at their Ides of March Event. The idea is you pony up $10 and enter your very bestest A&S project in a participant-judged winner-take-all competition. While I appreciate the squishiness of less intimidating A&S formats, I do believe in recognizing and rewarding excellence. (I may also be a bit on the competitive side.) I suspect this will draw some really amazing pieces by some of Northshield's best artisans (because some of them are pretty competitive too) and be an A&S display to remember.

Trewint's a good hike from Jara. I think I may go anyway.


********************************


And last, but by no means least, I am FINALLY getting some help at work! Starting September 8th, I will have a pharmacy minion to do my bidd... er... coworker to work with. One of the best parts is that she is interested in having Mondays off and so will work Tuesday through Friday and I can change my schedule to Monday through Thursday. This means no more staying up to obscene hours on Wednesday night at social, but it DOES mean a three day weekend pretty much every week. YAY! Even better, it means that something other than the bare essentials will be getting done at work. I have been keeping up with the patient profiles, the formulary development, the drug information questions, the prior authorizations, the mandatory federal reporting and the six dozen other necessary functions, but I have been coming home absolutely wrecked and still have not even been able to work on the special projects that would help address the financial, legal, and safety aspects of drug use that really are becoming somewhat urgent. (Shockingly, I've just not been able to keep up with ALL the aspects of FOUR peoples' jobs.) But soon, I will have help again and hopefully life will get a little less insane and my non-work motivation levels will start to rebound.

You've all been warned. ;)

Generally, my work interactions are only with the NPs, MDs, and other medical professionals. I only rarely need to interact with the patients directly unless I am running some specific patient-oriented activity like a medication brown bag or a public health seminar. Generally, when I do get a call from a patient it is a Bad Thing - they are usually angry about something and, whether or not it is my fault or a situation I can do anything about or whether it is even an actual problem (we serve a lot of patients with a wide variety of mental/psychological issues), they usually yell at me for some time before either calming down enough to talk to rationally or hanging up... Today, I got a call from the receptionist today literally two minutes before quitting time.

Receptionist: "Um, you're done in a couple minutes, right?"
Me: "Yup, what can I do for you?"
Receptionist: "There's a patient on hold for you. Mr. X... I'm sorry." (because she knows how this is likely to go...)
Me: *cringes internally* "OK, patch him through..."

**********************

Me: "Hello, Mr X, this is Dr. Hetzel, Pharmacy Service Manager, how can I help you?"
Mr X (obviously elderly Indian gentleman): "Yes, mum, this is Mr X. I have a question for you regarding ****"
Me: "OK, I can explain that to you..."
Mr X: "Oh, thank you mum."
Me: " *insert lengthy pharmaceutical coverage/review process explanation that none of you care about.* "
Mr X: "Oh, brilliant, mum! Thanks so much for explaining. I will return (requested form and information) to you straight away. Thank you, mum!"
Me: "Thank you, too"


First of all, I was shocked at how well this went - I was expecting some significant push back, especially from this patient, but he was all business and polite and perfectly reasonable. And then, being repeatedly called "mum" - it was just a little surreal. It was odd enough the first time I was called "ma'am" (I still usually get "miss"), but for some reason, "mum" scans as applying to some respectable middle aged to older lady. :P I felt like I needed a pillbox hat with some fake flowers and a little veil. *snerk*

So, Good Things: this cleaned up a problem the team had been having with this patient for awhile and made me giggle at the end of a long, hard day. Bad Thing: between accent and turn of phrase, now I'm REALLY missing Britain. :/

So, a moment of professional pride/bragging. For those of you who do not know, I am the clinical pharmacist for a program in Dane County (and soon others) that works to keep elderly and disabled people independent and in their homes as long as safely possible. We recently took on a new population because their previous program became financially unstable. It has been challenging in many, many ways, not the least because we lost a lot of staff in the changeover and we inherited many of the problems and concerns of the old program.

We recently got our drug cost figures for June and, while May was admittedly a particularly costly month, the June numbers were significantly down in my problem population... as in down nearly $100 per member per month! (granted, that still means we are still spending an average of $850 per member per month on drugs, but it is an improvement...) Some of the cost difference is from new generics, but some of it is from enforcing generic-only rules, Step Therapy protocols, therapeutic substitutions, and other hard work by the NPs and I.

This week was a particularly good week for cost-savings opportunities, so I am hopeful that I can continue the trend. For example - on Wednesday, I got a Prior Authorization request for a heavy-duty narcotic for a patient. I gave the PA, but in looking at his profile, I realized that a drug change or dosage adjustment was appropriate to address his incomplete pain control and over-frequent dosing intervals. So, I contacted the patient's NP, made my case and gave some suggestions, which she agreed to implement... except that she called me later that afternoon to tell me the patient had passed away. Now, remembering the narcotics en route to the patient's house from the pharmacy and knowing the patient's family was unlikely to turn down "free" narcotics just because the fellow was dead, I was able to quickly call the pharmacy and (because they had, indeed, requested to have it delivered) have them recall the delivery driver and cancel the prescription.  Yay! Avoiding narcotics diversion and saving $1500 in one fell swoop!  Earlier in the week, I had another lovely cost savings with no change to the patient opportunity. A patient was prescribed three 40mg tablets of a narcotic (of course) four times a day for a total of 480 mg. However, that is 360 tablets a month for a cost of about $2500! I made the prescriber re-write the prescription for 80mg tablets, two three times a day for a total of 480mg, a more reliable dosing schedule, and a cost savings of about $1400! Hurray for math! Trolling through claims data is boring in the extreme, but finding one drug billed as #28 for a 28 day supply (when it should have been #1 for a 28 day supply) and a compounded prescription that should have cost $40 that was billed at over 50 times that amount was certainly rewarding - to the tune of $4,500 without impacting the members at all! :)

Keep your fingers crossed for me... There is still a lot of work to be done in order to keep this program afloat, but I am hopeful I can do my part to keep it viable.