Granola bars, fruit snacks, and why I can’t buy them anymore.

You (probably) already know this, but I’ve got 2 kids – a 9 year old boy and a 7 year old girl. Like all children, they love snacks. I also love snacks. But when you buy a box of granola bars at Costco, you expect it to last for longer than a week. A family-sized box of chip bags for school lunches should make it past a weekend, and the giant value-pack box of fruit snacks should last for longer than the other two put together. Unfortunately, that’s not the world I live in.

To make matters worse, they don’t just eat 5 packs of fruit snacks, 3 granola bars, and 2 chip bags (each!) before sunrise every day when given the chance; they also leave a trail of wrappers through the entirety of our home like some kind of demented Easter bunny. Sometimes they’re out in the open, but more often they’re stuffed between couch cushions, hidden under chairs, wedged under pillows, and stashed in bookshelves. Sometimes they’re uneaten (like the melting ice cream sandwich I found in my purse recently), sometimes half eaten and forgotten (like the stale Christmas cookie I found in the way back of the silverware drawer in May), but most often it’s just the wrappers that make their way into places they don’t belong. Our efforts to get the children to clean up after themselves have been ineffective, and there’s literally nowhere in the house that these little monkeys can’t reach. So, in an effort to stay (a little) sane, we’ve decided to ban individually wrapped snack foods until they learn that we don’t live in a garbage can.

This has had the unintended consequence of making me really sad that I don’t have any snacks for myself, and irritated that the kids are no longer able to get themselves breakfast or a snack after school without adult help to prepare it (you do NOT want Emmett pouring milk into a cereal bowl on his own). So, obviously, I decided I’d just make some granola bars and fruit snacks on my own. How hard can it be?

Granola bars are tricky, because you want them to be (somewhat) healthy for the kids, but they also need to be tasty enough that the kids will actually eat them. Also, you need a granola bar to fill you up so you’re not immediately hungry again when it’s gone. So not an insane amount of sugar, lots of fruits/nuts/oats, and they have to stay together in a bar form. As it turns out, that last bit is the hardest part.

There’s always room for improvement, but I think I came up with something pretty tasty. I recommend not altering the sugar/honey/peanut butter amounts too much because they help it stay together, but if you want to reduce the sugar content you can use no-sugar-added dried fruits. So here’s my recipe for:

Yum!

(Almost) Perfect Granola Bars

Serving Size:
9-12 bars
Time:
1 hour
Difficulty:
Easy

Ingredients

  • 2-1/2 c. oats
  • 1-1/4 c. chopped nuts (I like 2 parts pecans to 1 part almonds, but use what you like)
  • 1/2 c. pepitas (can also use half pepitas and half sunflower seeds)
  • 2 tbsp butter
  • 1/4 c. peanut butter
  • 1/3 c. packed brown sugar
  • 1/4 c. honey
  • 1 tsp vanilla extract
  • 1/2 tsp salt
  • 2 egg whites
  • 1 c. chopped dried fruit (I’ve used strawberries, apricots, cranberries, raisins, blueberries, cherries, figs – it’s all good, just try to stick to 3 or fewer fruits)

Directions

  1. Preheat the oven to 400o. Grease a 9″ square pan with cooking spray, line with parchment paper, and grease the parchment paper.
  2. Combine the oats, nuts, and seeds on a cookie sheet and spread into an even layer. Bake, stirring every 5 minutes, until lightly toasted and fragrant. It should take around 15 minutes.
  3. Reduce the oven temperature to 325o. In a bowl big enough to hold everything, melt the butter and peanut butter with the brown sugar. Whisk until the sugar is dissolved, then stir in the honey, vanilla and salt. Whisk in the egg whites until thoroughly combined.
  4. Add the nuts/oats to the bowl along with the fruit, and make sure everything is covered in the sugar/butter/peanut butter/egg mixture. Spread evenly into the prepared pan.
  5. Grease another piece of parchment roughly the same size as the pan and place it (grease side down) on top of the mixture. Using your hands or a clean spatula, press the granola mixture down into the pan. This will help it to stay in bar form after it’s baked.
  6. If your top layer of parchment comes off easily (it should if you greased it well), then remove it prior to baking. If not, no biggie, you can leave it on until toward the end of the cook time.
  7. Bake until light golden, around 20-30 minutes. Under-baked bars will be tasty but won’t stay together. Over-baked bars will be bitter and gross. Unless you’re feeling confident, err on the side of caution.
  8. Let cool completely in the pan, then move the pan to the fridge until cold. Lift out and remove the parchment.
  9. Slice into bars with a sharp knife (a less-than-sharp knife won’t go through the nuts easily, and your bars will crumble). I prefer to cut 9 squares for bigger breakfast bars, but you can get 12 if you cut in the traditional “bar” shape.
  10. Individually wrap your bars in wax paper (like a little present), or, like me, stack the bars in two or three layers with a sheet of wax paper between each layer to prevent sticking.
  11. Store in a zip-top bag in your pantry for about a week, or in the fridge for 2-3 weeks. If you under-baked them a smidge and they’re falling apart, they’ll stick together better if you store them in the fridge. The freezer works too if you make a big batch. Let a bar thaw on the counter overnight for a quick breakfast the next morning.

Fruit snacks have proven a bit trickier to master, but I’m getting there. More on that later.

Why I became a pharmacist, and why that’s not the question that really matters.

One of the most common questions I get asked when someone inquires about my profession is, “Why did you choose to be a pharmacist?” My answer often strikes people as odd: “My high school chemistry teacher told me to.”

Like a lot of kids, I didn’t like school. I didn’t get the point of most assignments, and would frequently “forget” my homework at school, which got me into hot water on a number of occasions. I was, I’ll be honest, a pretty lazy student who was quite content to do the bare minimum. This continued to be an issue until I was about half way through high school. I don’t know if it was the knowledge that real life was fast approaching or if I just finally felt challenged and interested, but something finally clicked.

School wasn’t my thing.

Obviously there were still classes I didn’t like and areas where I didn’t fully apply myself, but I found that science class was my happy place. Chemistry and biology were my favorites, and I took every class available to me, including an anatomy/physiology course offered at my high school by the local tech college. I was able to take advanced placement classes in most of these areas, which actually translated into college credit, so I was able to get ahead of the game. I still struggled with completing the assigned homework, but I managed to convince most of the teachers in my preferred subjects that I was skipping homework because it was too easy, not due to lack of ability. Somehow that worked more often than it should have. 

I always knew what I wanted to be when I grew up. Sure, I dreamed about a lot of occupations, but I always KNEW I would go into medicine. I wanted to be a veterinarian, specifically. When I was around 9 years old I called every local animal shelter and vet clinic in search of one that would let me spend a day shadowing a vet or volunteering in some capacity. Most wouldn’t hear of it (apparently a 9 year old poses a liability problem), but I was undeterred. I was the type of child who was terrified of talking to strangers, so my insistence on cold-calling everyone in town was rather shocking. But I was determined to get my foot in the door, and finally found a clinic that agreed to let me spend the day with their veterinarian. She let me stay in the room when she examined the well-behaved animals, and showed me x-rays and patient charts (HIPAA doesn’t apply to animals, right?) to give me a feel for what she did every day. It was amazing, and I’m still so grateful to her and her clinic for taking me seriously and treating me like the little adult I thought I was.

As I worked my way through high school, I began to examine my future a little more closely. I realized that the tuition for vet school is insane, and they don’t get paid as much as they probably should. The general internet consensus is that it’s financially worth the cost of tuition, but just barely. Couple that with the fact that I don’t think I have it in me to euthanize a puppy, and I began to doubt the future in which I had once been so confident. But what were my other options? I still wanted to work in medicine, but could I be a nurse or doctor? To be honest, my dislike of physical human contact immediately turned those options into non-options.

Veterinarians have one of the highest debt-to-income ratios of any of the “high paying” professions. Basically, their schooling is hella expensive and they’re not paid well for it.

It was in this moment of hitherto unknown indecision that my high school chemistry teacher said, “You should be a pharmacist.” I come from a family of relatively healthy people, so I honestly had no idea what a pharmacist did apart from handing you a pill bottle, but I trusted this teacher’s judgment. As I looked into it further, I became more confident that this was the occupation for me. From that point on, my mind was made up and it was just a matter of making it happen.

My high school advanced placement classes gave me a leg up, and I was able to test out of some of the prerequisite classes. I was accepted into pharmacy school after only 2 years of undergrad rather than the typical 3-4, which made me one of the youngest people in my pharmacy class (I was 20 but looked closer to 16). I still struggled with studying, but there was no plan B to fall back on so failure wasn’t an option. Four years later, I was a licensed pharmacist. 

It’s what I do.

I’ve been a pharmacist for 12 years now, and I don’t think I regret my decision. I don’t enjoy my job the way I used to, but I’m happier now that I only work part time. I dislike what the profession has become over the past decade, but I still feel like I’m doing something worthwhile most of the time. 

So that’s the question I get asked most often, but here’s the question I wish more people would ask: What does a pharmacist do?

A pharmacist is a doctor who specializes in pharmaceuticals. They are, quite literally, a “doctor of medicines.” I’ll add a caveat here that a PharmD (doctor of pharmacy) degree has only been a requirement since 2004, so anyone who was licensed before that time may not technically be a doctor, despite being an RPh (registered pharmacist). 

The general idea is that a physician diagnoses an illness and prescribes a treatment, and the pharmacist’s job is to confirm that the treatment is safe and appropriate for that diagnosis. We verify that the dosage is correct for the patient’s age, weight, gender, and other health conditions, and that there are no contraindications or drug interactions with the patient’s other medications or health conditions. We also recommend alternative treatments when an insurance company refuses to pay for a drug, or when a patient can’t afford the medicine that was prescribed. Our technicians fill the prescription, and then we confirm that the drug in the bottle matches the drug prescribed. It’s also our responsibility to ensure that patients understand what drugs they’ve been prescribed, and have all the information they need in order to take their medication correctly. We warn patients of potential side effects or drug interactions to be aware of, and what they can do to manage minor side effects at home. We act as a sort of triage for minor injuries and illnesses, and spend a decent amount of time answering questions and instructing our patients about what OTC medications and treatments are appropriate for their situation, and when they should seek medical attention. We also administer vaccines to anyone over the age of 3 (age varies by state).

Because the American healthcare system is broken, our “real” job (everything in the previous paragraph) isn’t viewed as being very important by corporate America or the general population. Most of what we do isn’t seen by the public and can’t be monetized (patients seem to think their doctors don’t make mistakes, and I can’t charge someone for asking if they can take Motrin and Aleve together), so our corporate overlords have come up with other ways for us to be “useful.”

PBMs have sucked a lot of the profit out of dispensing medications, but we still need record-breaking profits every year so we’re being asked to do more with less. Hours get cut so that pharmacists have to do their own job as well as the jobs of technicians. We’re asked to do MTMs (“medication therapy management,” or in-depth 1-on-1 consultations with patients who take multiple medications to treat a multitude of illnesses) without pharmacist overlap or extra help, and corporate wants us to cold call people to badger them into signing up for additional programs and services that they don’t want. Don’t get me wrong – MTMs are incredibly important when done right, and auto-filling prescriptions can improve compliance, but we’re doing it all wrong. I can’t do a proper MTM while filling prescriptions at the same time, and we frequently auto-fill medications that people don’t even take anymore. It can’t be about the number of people we sign up for these services, but about how these services can best be utilized to serve our patients. As it stands right now, all the emphasis is placed on the number of prescriptions we can fill, MTMs we can do, and vaccines we give, rather than on whether we’re actually keeping our patients safe and healthy.

From the Journal of the American Pharmacists Association – our skills are being underutilized. We’re not doing what we’ve been trained for, and our patients are suffering for it.

I wish I could say that it was just a single company’s problem, but it’s trickled down from the big 3 (Walgreens, CVS, Walmart) to include pretty much every pharmacy except the few independents that haven’t yet been bought by the chains. The emphasis placed on metrics and customer satisfaction surveys have meant that I’m no longer able to properly use my professional judgment to ensure the safety of my patients. We do the best we can with what we’re given, but we’re not given much. Patients care more about getting their medication quickly than safely, and don’t want to hear that it took longer than expected because their doctor accidentally prescribed clomiphene (for infertility) instead of clomipramine (for OCD or depression), or because they pushed the wrong button on their calculator and prescribed an overdose of an antibiotic to an infant. They don’t want to wait for the pharmacist to walk over and counsel them on how to take their medication (even though I’m legally required to talk to them) because “the doctor told me how to take it.” These are, inevitably, the people who call an hour later to ask what the drug they picked up is for, if they should take it with food, or who stop taking it entirely because it’s making them queasy. The introduction of the drive-thru has made us synonymous with fast food in the eyes of many, and the “$4 generic” program started by Walmart has made it clear that it’s the pill bottle they’re paying for, and we as healthcare professionals have nothing of value to offer.

A survey of American pharmacists showed that more than half of pharmacists working in a chain retail pharmacy believe that their employers are actively working against the best interest of their patients. They don’t care how many patients get hurt so long as they’re still turning a profit.

There’s a saying in pharmacy that goes “You can get your medication fast, cheap, or safe. Pick two.” Unfortunately, safety has taken a backseat. I don’t regret my decision to become a pharmacist. I still feel like I’m making a difference. But if I had to do it all again, knowing what I know now, I don’t think I’d make the same choice. The question I keep asking myself now is this: “Is it better to keep working in retail and fight for the safety of your patients, or should you get out while you can before your employer’s reckless pursuit of profit causes you to make a mistake that causes serious harm?” I’m still working out the answer to that one.

My kids dress themselves

Experts say that kids should be allowed to choose their own clothes, as it fosters a sense of independence and allows them to express themselves in a world where they don’t get much of a say in their day-to-day activities. I’ve been letting my kids dress themselves from a very early age, and it only sometimes backfires.

My son’s clothing choices are pretty standard. Jeans or khakis and a graphic tee are his go-to, though he’s been known to rock some brightly colored hair and nail polish from time to time. I pretty much only need to intervene when he wants to wear shorts in the dead of winter. And I love when he decides to wear a button down shirt over his T-shirt because he says it makes him look “fancy like Hamilton.” He’s such a handsome fella no matter what he wears.

He’s Knuckles, btw.

My daughter is another story. She takes the whole self-expression thing to another level with her fashion choices. She once said, when she was barely out of toddlerhood, that she had “a passion for fashion – I would die for fashion.” Dramatic much? While I respect her autonomy and want to let her wear what she wants, sometimes I need to put the kibosh on her wilder ideas. Color clashing is fine, and a fancy dress at the park is okay by me, but a full-length ball gown with a giant hoop skirt is too extra for school. But as long as it’s not a safety issue or a distraction to her classmates, I honestly don’t mind whatever she wants to put on her body so long as she’s clothed.

I know some of the things she wears are silly; recently, she wore a fancy white dress (it was probably supposed to be a flower girl or first communion dress) to her cousin’s backyard birthday party. Impractical? Yes – she got black frosting on her white skirt. A problem? Nah, I can wash it. She also wore a pioneer-style bonnet to school recently. Did I think it looked silly? Sure. But she was confident in her choice, so whatever.

I made that bonnet in 3rd grade. Not really sure why I still have it, but she found it so it’s hers now.

Basically, I think kids will have enough self-doubt, insecurities and peer pressure to be just like everyone else during their tween and teen years. All I want is to encourage them to be fully themselves while they still have the unbridled confidence of youth. When they finally emerge as young adults I want them to feel comfortable being weird again, and to heck with the people who try to crush their spirits. Weird people are my kind of people.

Terrifying

Fun story:

Last night, I came home from work and locked the chickens up. Usually they’re asleep on their roosts when I do this, but last night they were awake and pacing around their coop. I figured they were just cranky that I turned on the light. This morning when I let them out, I checked their nest boxes just in case (they have to start laying eggs eventually, right?). I got to the middle box and was greeted by this:

Not my picture – I was not in a picture-taking frame of mind. On the bright side, I didn’t scream. I’m proud of me.

It’s an opossum, so the second it saw me it went into “I’m dead but I still have teeth so don’t touch me” mode. It was just frozen there, with its mouth open as wide as it goes and its eyes shut tight. Now what? The chickens were all unscathed – it appears that it was just looking for a warm place to sleep, so there’s that.

So how do you move an opossum that’s playing dead? Should I poke it with a stick? I didn’t want it to move further into the coop, because then it’s harder to get it out. Could I just pick it up? Probably not a good idea. But maybe? But no, not worth losing a finger.

I went back inside to see if maybe it would just leave. Wishful thinking, but that would be the ideal situation, right? When I was out of sight, he just turned around and went back to sleep. Damn.

I went into the garage to look for something to forcibly remove it, and settled on a pitchfork. I went back out there and tried to scoop it up. The pitchfork is just a bit wider than the nesting box, so I couldn’t angle it right to scoop under the animal. I tried using it like a rake to pull the critter out. It clung tighter to the wood and refused to budge. Apparently I wasn’t even worth showing its teeth to anymore, because it was keeping its back to me as it continued to death-sleep.

I went back into the garage and chose a shovel. This possum was about the size of a cat, so it was filling up the nest box pretty good. I did manage to maneuver the shovel under the possum, and I started to lift it out. It was surprisingly heavy. I was slowly walking with a possum on a shovel, wishing someone else was around to experience this absurd moment with me, looking for a place to put it. I wanted it out of my yard, but I couldn’t just chuck it over the fence. It’s terrifying, but I didn’t want to hurt it. I wanted to find it a warm place to sleep, but I didn’t want it to feel at home in my yard. As I was mentally working my way through this moral dilemma, this freaking possum is sitting at the end of my shovel, facing me, mouth open wide, frozen to the spot, but with a look in its eyes that says “I may be dead now, but one wrong move and I’ll eat your face.” In the end, it intentionally fell off the shovel while still playing dead, made sure I wasn’t going to eat it, and slowly waddled away into the forest.

So that was fun.

I’ve had better days

It’s Wednesday, and I have a plan. But, as the saying goes, the best-laid plans of mice and men often go awry. Or, in this case, chickens.

So here’s what’s on my agenda – teach a class, go to work, pick up the kids from school, stop at home and start a batch of bread, let the kids grab a snack, head off to Em’s reading lesson, come back home, get the dough in a pan for its second rise, make dinner, bake bread, clean up, finish Madeline’s Halloween costume, watch a little TV, go to bed. It’s an excellent plan.

My morning class goes well. So far, so good. I go into work early to get a head start on the day, but then I look at the schedule and it’s just me (the pharmacist) and one technician until 1:00. That’s not good. Like, really not good. With vaccines scheduled every 5-10 minutes, it’s physically impossible to both vaccinate and fill prescriptions. Thankfully, another pharmacist can come in for a few hours to help me out. Even so, it’s hectic. Is it really so difficult to be kind when you can see people are struggling just to keep their heads above water? We’re not trying to make you late for whatever you need to get to, but we ARE trying to avoid making a mistake that will kill you.

I pick up the kids from school, and as we’re driving away Emmett informs me that he forgot his hat and his lunch bag at school. Great. Minor hiccup, it’s fine, we’ll get them tomorrow.

We arrive back home to see that the kids’ Halloween pumpkins have been knocked off the porch. Emmett is distraught, and on the verge of tears. Thankfully nothing was damaged by the fall, but it takes a bit of searching to find the lids and candles in the yard. I get my bread dough going.

After some coaxing, I manage to get the kids ready to go to reading class. We’re running late because Emmett wanted to keep playing his video game, but that’s fine. We’ll only be a couple of minutes late. On our way to the car, a police officer pulls up and gets out of her car.

“Did you lose a chicken?”
“….. uh … I didn’t think so?”
“I’ve got one in the car. I’ll bring it out and you can see if it’s yours.”
“Okay… “

I look in the pet carrier, and sure enough, it’s my best hen. “Best” in the sense that she’s the only one who’s even remotely friendly (the others aren’t mean, but they’re very aware that I’m not opposed to eating them).

“She was found a couple of blocks away. She followed someone into their house.”

I don’t even know how to respond to that. I think I just stared at her with my mouth open like a fish as I contemplated how one of my chickens could have wound up in someone’s house a several blocks away. I keep my hens in the back yard, and they have a super secure chicken coop with locks on all the doors. I just finished redoing their run to make it more secure (it took forever) and I was sure there was no way a chicken could get out. For those of you not versed in chicken vocab, a “run” is a fenced in area where they’re allowed to roam. Their roaming area is penned off with 7′ high deer fencing (a super strong net designed to keep deer out of your garden) that’s attached to the ground with stakes and to the trees with zip ties. How could they get out?

“Mom, look! A chicken!” I think she’s talking about the one I’m holding, but then I see it. Staring at me, not 5 feet away, her head cocked to one side as if she’s confused about what I’m doing out here, is a chicken. I’m already holding a chicken, so I tell the kids to back up slowly so they don’t startle her, and I run to the back to put the chicken I’m holding back into the pen.

I run back to the front yard, and the chicken is still there. Madeline is jumping around like a crazy person, and it starts to back away. I tell Madeline to get in the car with her brother; I need to catch this chicken quick so we can get to reading class.

The chicken has decided that she’s not interested in being caught. She’s made her way over some rocks, down a steep incline into the wooded area next to our house, and I try to follow her (we don’t own it, and neither do our neighbors, so I’m free to traipse through). I’m getting nowhere with this. She’s managed to find a spot that I can’t reach, and settles in for a nice roost. I make a quick phone call to tell his teacher that we’ll be late for his reading lesson.

See the chicken? She’s behind those thorny bushes at the bottom of the hill. Can’t see her? It’s okay, I can’t either, but she’s in there.

I go back inside and grab a beef stick to lure the chicken out of her hiding spot. I make my way back down the slope, and try not to loose my footing on the slippery rocks and loam. I manage to find a big stick, and I poke the chicken with it. I’m swearing at the chicken with reckless abandon. She finally starts to move up the narrow escarpment, giving me angry clucks for disturbing her. I find a safer area to climb up where I can still see her. She’s back on our lawn, and there’s no beef stick. Madeline comes running, and the chicken starts to turn around.

Yes, it’s a steep hill. And yes, those rocks are slippery. I mentally prepare myself to call 911 if I break a leg.

“Madeline! Where’s the beef stick?!?!”
*blank stare*
“What the fuuuuuu… Madeline!!! That was to keep the chicken up here so I can catch her!!”

*throws chips at me* ……. I don’t know why she thought that showering me with Dorito fragments would appease me, but I’m now slightly worried that my face may be turning purple.

[email protected]#U$##)@(#[email protected]*#[email protected])(*)(# GET BACK IN THE CAR AND LET ME CATCH THIS G** D*** BIRD!!!”

After way too much effort, I manage to coax this mother fucking bird into following me, but she’s wary. I think I can get her into the garage, so I give it a go. Madeline is in the front seat of the car because of course she is, so I tell her to close the garage door when the chicken gets in. I’ve finally got her cornered. I caught her! Success!

I bring her back to the pen, and put her in with the others. I do a quick count, and there are … 5? That can’t be right. I open up the coop to search for the others, but to no avail. I’m missing 5 chickens. God damnit.

We were supposed to be at reading class a half hour ago. I call them to say that we won’t be able to make it. Our back “yard” is a jungle. They could be anywhere. And the two I just put back weren’t even in the yard. I’m at a bit of a loss, and don’t even know where to start looking. I tell the kids to get out of the car and go inside. Play, watch TV, I don’t care. This is going to take a while.

I find another one hiding out in that same rocky wooded area on the right side of our house, so I go through the whole rigmarole again. She was apparently watching while I captured her friend, and she wasn’t falling for it again. I manage to get her over to the left side of the house (the side with the gate leading into the back yard), but she decides to take another left and check out the neighbor’s side of the fence. I can’t even get over there, because the trees and forest debris are so dense. I try to come at her from my side of the fence. Maybe I can shoo her back toward the gate and get her in here. I can barely reach the fence through the mess of fallen trees and shrubbery, but I manage to poke her with a stick. She just backs up a few inches so I can’t reach her again with the stick. I say “fuck it” and walk away. She knows where I am, she can come when she’s ready.

See the metal fence way back there? She’s on the other side.

I go back to their pen, and try to figure out how they all got out. I hear a car honking its horn, which is annoying. But it’s coming from really close. It’s my car. Why!?!! I run back to the front, and Madeline has the car turned on (the lights and radio, not the engine), the hazard lights are on, the brights are on, she’s honking the horn, music is blasting, and she’s eating another bag of chips. I suddenly know how volcanos feel right before an eruption.

I forcibly remove this child from my vehicle, turn everything off, and tell her to get her ass back in the house. Her chip bag is now empty, and I tell her that she can play or watch TV or whatever, but she’s done snacking. Emmett pokes his head out the front door and asks if he can have a snack. He hasn’t had one yet, so sure. Whatever. Go for it.

I head back into the yard, and see that the deer fencing has been ripped out of the zip ties on one of the trees, and is practically on the ground. That’ll do it. I attach it back to the tree in multiple spots for added security. Okay, we’re good. I hear Emmett scream crying. Did he crack his head open? A broken arm? Surely he’s severely wounded in some way.

No. Madeline is back in the car, and she has stolen Emmett’s snack. He’s sobbing hysterically, which seems excessive, but he can be an emotional child. She’s already eaten all of his snack. I’m ready to reign violence down upon this girl, but Emmett is already sad enough so I keep my shit together and summon the angriest mom eyes I can muster. It’s not difficult. Emmett gets a new snack, and Madeline gets threatened with a lifetime in solitary confinement if she doesn’t get back inside. She’s banned from all food until dinner.

I go back to the fence, and see that the netting has actually ripped through a lot of zip ties. What even happened here? I get a big roll of twisty ties, because I’m all out of zip ties. I make repairs where I can. I see another chicken. This one looks wily. I slowly make my way behind the bird, making sure to not make eye contact. I don’t think I can catch this one, because I have nowhere to corner it.

I’m slowly walking around the chicken pen, letting the chicken lead the way, and trying to keep it walking along the fence. If we can make it to the end of the fence, I can corner it where the fence meets the coop. Madeline bursts onto the scene shouting “WHAT ARE YOU DOING?!” The chicken realizes it’s being stalked and takes off in the opposite direction.

I’m about ready to lie face down in the dirt and stay there until nightfall.

Chasing this chicken is getting me nowhere. I’m just making it run farther away. Instead, I go to the fence “door” (the spot where I can get in and out) and open it. I tell Madeline to make herself useful, because she’s clearly going to ignore every order to go inside and behave herself. Her job is to stay at the entrance, make sure the chickens already inside don’t get out, and if another chicken comes close she should stand still and let it walk inside. Sometimes they just want to come home on their own terms.

The rogue chicken is in sight again. I figure I’ll try ignoring it, and see if it walks in on its own. Madeline starts shouting and pointing “THERE IT IS!!” After another reminder that her job is to stand there quietly and make sure chickens don’t escape, the bird starts to slowly make its way toward the entrance. We’re getting there! I start to walk behind it again, just to make sure it doesn’t change its mind and turn around. She’s on to me, and decides that she doesn’t want to play this game.

Change of plans. I’ll turn around. She clearly doesn’t want an audience. Madeline says “Hey, Mom! I’m in the chicken cage!” and yes, she is indeed in the pen, at the end farthest away from the entrance, and I can see a couple of curious hens inching toward the exit. I ask her how it’s even remotely helpful for her to be inside the pen when she’s supposed to be guarding the exit. She seems confused by the question. I feel like I’m in that Monty Python and the Holy Grail scene with the dad talking to his son’s guards in the tower:

“You stay here, and make sure the chickens don’t leave the pen.”
“Right. I don’t need to do anything apart from just stop them entering the pen.”
“LEAVING the pen.”
“Leaving the pen, yes.”
“Alright?”
“Oh, if, if, uhhh, if uh…. if they…”
“Look, it’s quite simple. You just stay here, and make sure they don’t leave. Alright?”
“Oh, I remember, can they leave the pen with me?”
“No, you just keep them in here, and…”
“Oh, yes, I’ll keep them in here, obviously. But if they had to leave and I was with them…”
“No, just keep them in here until I come back”
“Right. I’ll stay here until you get back.”
“And make sure they don’t leave.”
“What?”

I decide that nothing about this is going to work, so I close up the exit and tell Madeline, with my head in my hands, to please just leave and clean her room or something. Obviously she won’t, but I can dream, right? I keep checking the zip ties, and make repairs as I see them.

My yard. It goes back a looooong way. These chickens could be anywhere.

The chicken is back, but I don’t even care anymore. There are 5 chickens in the pen. No, wait, I’m counting 6. What? And now, as I’m watching this god damn bird walking toward the side of the pen, it just walks through the fence. Oh my effing god. I have 7 now, but WTF just happened?

I go over to the part of the fence where a chicken just Houdinied her way in, and, sure as shit, there is a hole in this fence so big that I could walk through it. As I’m patching up this hole, another hen somehow appears in the pen. At this point, it’s around 5:00, and I’ve just about had it. I’ve gone around the entire fence and patched half a dozen big holes. Chickens didn’t do this – it must have been a predator of some kind. Raccoon? Opossum? Fox? Coyote? Chupacabra? Whatever it was, it tore this fence up bad.

It’s now 5:30, I’m done making repairs, 8 out of 10 chickens are locked in the coop, and the other 2 are nowhere to be found. I’m done. I’m not even emotionally attached to these birds. They don’t have names, I don’t even remember what they all look like. But this day has been a little too much. I decide to skip making dinner, and we order a pizza instead. I spend some time lying on the floor of a dark room and trying to pull myself together. I do, eventually, remember to bake the bread, and I finish Madeline’s costume, so the day’s not a complete loss.

That was Wednesday. It’s Friday now, and I’ve been working on building another fence outside the current fence with T-bars and heavy gauge chicken wire. It’s been raining, so it’s slow going. I’m about half way done, and I’m hoping it dries out enough over the weekend to keep working on it. I think the 2 I lost have probably been eaten, but I can’t say for sure. I might wake up one morning to find them clucking at me to let them back in the coop. It wasn’t a great day, but it’s kind of funny now in retrospect.

It’s Hickory Season Again!

If you’ve been hanging out with me for a while, then you may remember that I wrote about foraging for wild hickory nuts way back in 2018. If you’re a more recent follower, odds are that the hickory nut post is what brought you here! It’s the most popular post on the site, and I get it. They’re delicious!

A word on hickory nuts, though – if you shell more than you’re going to use right then and there, keep the shelled nuts in the freezer. They keep basically forever when frozen, but they’ll go moldy pretty quickly at room temp or in the fridge because they have a high moisture content (ask me how I know). In the shell, they’re good for quite a while, so if you’re short on freezer space then don’t crack them open until you want to use them. You could also dry or roast them, but hickory nuts have a much higher moisture content than most other nuts, and I find that it’s easier to just freeze them.

So if you’re like me and you think found food is the best food, then I’ve got a recipe for you to try. While hickory nuts (a buttery-tasting relative of the pecan) are delicious in a variety of applications ranging from cakes to muffins to ice cream, my very favorite way to use them is in a shortbread cookie. It’s kind of like a pecan sandie, but better (in my opinion). Give them a try!

Tasty!

Hickory Nut Shortbread Cookies

Serving Size:
30-36 cookies
Time:
30 min active, chilled overnight
Difficulty:
easy

Ingredients

  • 1 c butter, softened
  • 1/4 tsp fresh orange zest (optional, but delightful)
  • ½ tsp salt
  • ½ tsp vanilla extract
  • 2 c flour
  • ¾ c powdered sugar
  • ½ c hickory nuts

Directions

  1. Cream together butter, zest, salt, and vanilla. In a separate bowl, whisk together flour and powdered sugar. Add the flour/sugar mixture to the butter mixture, and mix until just combined. It’s going to look very crumbly. Finally, stir in the hickory nuts.
  2. Dump out the cookie dough (it’ll probably seem too dry) onto a large piece of plastic wrap, and use the plastic to form into a log approximately 2 inches thick (you can also use parchment paper if you’re opposed to plastic). Make sure it’s nice and compact, with no air bubbles. Refrigerate overnight, or 2 hours minimum if you’re in a hurry.
  3. When ready to bake, preheat the oven to 350o and cut cookies into 1/4 – 1/2″ slices. Place on a cookie sheet lined with parchment paper or a silicone mat, leaving about 1″ between cookies (they don’t spread much). Bake for 10-12 minutes, or until done to your liking. I like to cook mine until the edges start to turn golden brown but the main part of the cookie is still white.

That’s it! How easy is that?! I like to keep my uncooked “roll” of cookie dough in the fridge, and slice off a few cookies at a time to bake here and there when I’m feeling snacky. If I made them all at once, then I’d have to eat them all at once (well, I guess I wouldn’t have to eat them all, but I probably would anyway).

Happy baking!

It probably won’t last forever

It’s been a busy summer! We moved about a month ago (maybe 2 months? Time is flying by), and we’ve been working hard to get unpacked and settled in. I only have one room left to finish unpacking (my craft room), and we’re still waiting on a new couch and kitchen table to be delivered.

We’ve learned a few lessons since we moved, and things are going much smoother now.

  1. If you can’t find Madeline, she’s probably at the neighbor’s house (her name is Cathy, and she’s Madeline’s new BFF. She’s also probably in her 70s, but Madeline doesn’t care).
  2. The best way to stop Madeline from waking Cathy up at 5:30 in the morning is to get some better locks. I recommend a lock with a combination keypad. Put it on backward so that you need to enter the code to exit the house.
  3. Put a lock on the garage door, too. She’s crafty like a fox.
  4. Ban all outdoor time unless under the direct supervision of a parent or teacher for the remainder of the summer.

In other news, while searching for furnishings for our new digs, we found a comically large roll of toilet paper. Of course we bought it, and I have to share it with you. You know those really big rolls that you need to buy an extension for so that it fits on the wall dispenser? This one comes with a stand-alone holder, because it’s that big. We’re talking the size of 11 or 12 “normal” rolls. It’s massive.

Just look at it. It’s ridiculous.

I seem to be the only person in this house who knows how to put toilet paper ON the wall roll holder, so this is just *muah*

It’s like those big rolls they use in retail store bathrooms, but this is regular, 2-ply, so soft toilet paper.

We didn’t put it in a bathroom the kids use (even I’m tempted to put the end of the roll in the toilet and flush to see what happens), but I’m just psyched that it exists and that I have it in my house. If you’re wondering, it’s called the Charmin Forever Roll. I have my doubts about the “forever” part, but it certainly looks possible. They’re not paying me, but if any Charmin execs are reading this I’ll gladly continue to sing your praises.

Oh, also I got 10 chickens. That’s something people do, right?

The prescription pricing system I’m not allowed to talk about.

It’s been a while since I’ve written about anything that matters, but this is something that’s incredibly important. There’s been a lot of talk about the rising cost of drugs in America, and we’re so eager to place the blame at the feet of pharmaceutical companies that we’re completely ignoring the role that PBMs play in all of this. Pharmacists like me have been shouting “Why isn’t anyone talking about the PBMs?!” But it’s hard for non-pharmacy people to talk about something they’ve never heard of. PBMs operate in the shadows, and that’s just the way they like it.

Today we’re going to get down in the weeds and talk way too much about the real reason your drugs cost so much. I’m going to provide you with as much information as I can without risking any repercussions from my employer (I do, in fact, need to keep my day job). Graphs and other visuals in this post are not my own, but I have independently verified their accuracy – references are at the bottom. I realize that this will be way more than most people care to know, but knowledge is power and we need all of it we can get to change our broken healthcare system.

PBMs, or Pharmacy Benefit Managers, are what we typically think of as “prescription insurance.” They’re not really “insurance” on their own, but they like to pretend that they are. They use the same words as health insurance – copay, deductible, prior authorization, etc. But what a PBM actually does is act as a middleman. Your health insurance includes coverage for prescription drugs, but they don’t actually deal with pharmacies directly. A PBM takes money from your insurance company and handles the negotiations and payments on their behalf.

Most people understand how health insurance works, at least in a general sense. Your insurance company enters into a contract with either you as an individual, or with your employer. If you pay a certain amount each month, the insurance company will negotiate with healthcare providers on your behalf, pay a portion of your medical expenses (if you’ve met your deductible), and you will only need to pay a small portion of your medical bills out of pocket. If you look at your bill, you’ll clearly see how much the doctor or hospital charged, what the insurance company paid, the lower price they negotiated on your behalf, and what you’re expected to pay. We might not understand why a hospital charges $12 for a single ibuprofen tablet, but we at least understand how it’s being paid for when we see our bill. PBMs are different. A lot different.

PBMs began to pop up in the ’70s, and really started to take off in the late ’80s and early ’90s. Before that time, prescription drugs were relatively inexpensive, and there weren’t very many medications on the market (at least not like we have now). As time went on, insurance companies found it more and more difficult and costly to keep up with the pharmaceutical boom, and someone had the bright idea to approach an insurance company and offer to deal with the pharmacies and drug companies on their behalf. How kind of them.

I don’t want to underplay it too much – drugs are definitely expensive, and PBMs do a lot of work that should help lower the cost of medications. They develop and maintain a formulary, contract with pharmacies, negotiate discounts and get rebates from drug manufacturers, and process and pay for prescription drug claims on behalf of insurance companies. That’s no small feat, and they should absolutely be compensated for the work that they do. The idea is that a PBM will have better luck negotiating lower drug costs than the insurance companies themselves can do, and that savings is supposed to be passed back to the insurance company, which should then pass that savings on to the consumer in the form of lower copays/deductibles/premiums. Isn’t that just the funniest thing you ever heard? Yeah. It doesn’t work.

Insurance plans are relatively transparent about where the money goes. You can see it right on your bill, and they’ll explain it to you in detail if you call them. However, PBMs (the middlemen) are not open and transparent about how your medications are paid for. In fact, when a pharmacy contracts with a PBM, part of that contract says that pharmacy employees are prohibited from telling patients any details about pricing and/or payments received from the insurance company. That’s right, folks. I know how much the wholesaler charges the pharmacy, I know how much the pharmacy bills the PBM, and I know how much the PBM pays the pharmacy. I’m not allowed to tell you any of the details. I’m. Not. Allowed.

So please explain to me how people are supposed to be financially smart about their healthcare decisions. You can’t “shop around” for the best price on a medication when the entire pricing system is a secret. There’s no competition in the market when nobody knows what anyone else is charging or paying.

Let me give you a specific example, without giving you more information than I’m allowed. I’m going to make it clear what details I’m not legally allowed to share just to point out the ridiculousness of the whole thing. One of my medications (I can’t say which) costs $452 without insurance. I haven’t met my deductible yet, meaning I’m paying out of pocket, so my kind and generous PBM (I can’t tell you which one) has negotiated a lower price for me and I only paid $89 today. Thank you, PBM! I feel #blessed to have insurance.

But this medication cost my pharmacy (I can’t say which one) $5.61 to purchase from our wholesaler (I can’t tell you which one). I’m paying $90 for $5 worth of medication. Cool. But get this – the random dollar amount that has been set as the “recommended list price” (also called AWP, or “average wholesale price” – it’s a made-up number without any basis in reality) for this medication is $566. What?

While it seems like the pharmacy is ripping me off here, I also filled someone’s prescription the other day that cost us $3.04 to purchase from our wholesaler, the patient had a $5 copay, and the insurance paid us $-4.85. Yes, you read that right, they didn’t give us any money, WE had to pay THEM as.. what?.. an offering to the PBM gods? Oh, and the AWP for this drug was $474, with a “cash pay” price of $305, because that makes sense. Losing money isn’t super common (pharmacies are for-profit businesses), but it does happen. Our contracts with PBMs say that we can’t turn people away if we’re losing money on a prescription, even if we’re losing a lot. The whole system is effed.

Obviously, every company has overhead expenses, employees to pay, and needs to make a profit. This is America, after all. If we’re not profiting off someone’s misery, we’re doing it wrong. But PBMs have actually created the drug pricing system we have today, and I would argue that they are a major reason why drugs are so expensive.

When you buy something like a TV, it’s made by a manufacturer, sold to a wholesaler, sold to a store, and sold to the customer. The price goes up a bit with every transaction. That makes sense, right? Drugs are also products that go through this same process, so the price should also increase a bit with each transaction, right? Wrong. Or, rather, it would be right if not for PBMs. Let’s follow the money.

Americans spend a lot on prescription drugs, and costs have risen exponentially over the past 20 years. I couldn’t find any graphs with the current numbers, but I still like the visuals. I’ll let you know the current numbers (for the year 2020) as we go.

The Real Price of Medications | U.S. PIRG
Wowzers, what the heck happened?

In 2020, Americans spent $393 billion on prescription medications. Most sources will give the “average amount spent on prescriptions” (by insurance, the government, patients, and charities) of $1200/person, with out-of-pocket costs averaging $168/person. It’s doable for most people when spread out over a whole year. But, given that only 40% of Americans actually take prescriptions, this number doesn’t give you a good picture of what’s really going on. The ACTUAL amount spent yearly by people who take prescription medications is $3004, with an average out-of-pocket cost of $420 per year. Not sure how that stacks up? Americans spend more than twice as much on prescriptions as people in other countries. And most other countries don’t have any out-of-pocket costs. It’s not because we’re taking better drugs – they’re literally the same medications. We just pay more.

The numbers have gone up a bit since 2017 (see above), but the percentages of who’s paying have stayed roughly the same.

You’ll notice that the fine print in the above chart says that these numbers are taking rebates into account. This is important to note, because nobody knows how much money is saved by rebates. Why? Because PBMs don’t want you to know. We’re all in the dark on how much money is actually spent on prescriptions in America, but we think these numbers might be a close estimate. Maybe.

So that’s a bummer and all, but that’s just the way it is, right? Prescriptions are expensive, we pay for them to stay alive, end of story. But it didn’t use to be like this. Because of inflation, we expect prices to go up a bit every year. That’s expected, we get it, it’s how things work. But the cost of prescription drugs has risen so much more than inflation that it’s getting seriously out of hand. And there’s no reason for it! Well, except for PBMs (I’m imagining a PBM as a type of mustache-twirling Snidely Whiplash character). And we just let it happen, because what can we do? This is America, and prices can go up up up as high as people are willing to pay.

Branded drug pricing has well outpaced general inflation in every year over the past decade.
The orange line shows the inflation increase from year to year, the blue bars show the inflation of prescription drug prices. Trust me – it’s only gotten worse since 2015.

Okay, so we can all agree that prices have gone up, and it’s becoming unsustainable. But how do PBMs actually play into this? Don’t manufacturers, insurance companies and pharmacies share a lot of the blame here? Absolutely. But I’d argue that the different components of the pharmaceutical industry don’t exist in isolation. What one company does affects all the others. PBMs are the first domino to fall, and their actions directly affect how every other business in the industry operates, to our detriment. Let’s see why.

First off, let’s establish something important. Medication doesn’t have a set cost. It’s a bit like gasoline. The prices change from one day to another, from this gas station to the one across the street, and from region to region. But, unlike gasoline, nobody knows what anyone else is paying for prescription drugs. Makes competition in a supposedly capitalist market impossible, right? Yup.

On top of that, prices are affected by rebates and discounts given by manufacturers to wholesalers, pharmacies and PBMs. And these rebates aren’t insignificant. In 2015, more than 1/3 of a brand medication’s “list price” was discounted in some way. It’s like how Hobby Lobby says “Furniture is always 30% off the advertised price!” Like, okay, but then why don’t you just put the actual price on the sticker? If something is always on sale, then just change the price to that. Except that rebates are a secret. A manufacturer might give a 20% rebate to my insurance company, a 50% rebate to your insurance company, and might make another company pay full price. And nobody knows who’s getting what discount, or if other companies are getting them at all. Remember how I said earlier that Americans spend $393 billion each year on prescriptions? It’s estimated that rebates and discounts on prescription drugs (remember, we’re just guessing here) exceeded $100 billion last year. That’s crazy.

w26846
For real, though. This is just for brand name drugs. The spread between the “list price” and the actual price is substantially bigger for generic medications.

You can see in the above chart that while drug prices are certainly rising, rebates and discounts are rising faster. What does that mean? It means that PBMs are receiving more rebates and discounts every year, and they’re clearly not passing that savings on to their customers.

So where does the money go? Drugs travel how you’d expect: manufacturer –> wholesaler –> pharmacy –> patient. The money should flow the opposite way, right? The patient pays the pharmacy, the pharmacy pays the wholesaler, the wholesaler pays the manufacturer. Nope. Here’s what actually happens:

Not following? There are too many “dollar flow” arrows here, right? This is where it gets interesting. (and there should actually be a green arrow going from “patient” to “health plan,” but that’s okay)

First, a patient (or their employer) chooses an insurance company. The insurance company hires a PBM, and pays them to negotiate lower drug prices on their behalf. The PBM then acts as a “funnel” to transmit payments from the insurance company to the pharmacy. With me so far? Everything is working how it should. But here’s where the PBMs work their magic. Somehow, all the “payment” arrows wind up pointing to them.

The health plan pays the PBM. The pharmacy pays the PBM for the “privilege” of getting paid (I know it doesn’t make sense, but we do actually pay a set fee for every claim we bill, even if that claim is later reversed and the patient doesn’t get their prescription). Discounts and rebates that the PBM negotiates don’t get passed on to the patient, they get secretly refunded directly to the PBM. The PBM is supposed to report back what discounts and rebates they’ve received and pass it on to the insurance company (minus a small fee for their trouble), but they don’t – at least not as much as they’re supposed to. When health plans DO receive their share of the rebate or discount, they’re supposed to use it to lower premiums, copays and deductibles for their members. They don’t (at least not as much as they should). Get the picture? Why is anyone surprised that when a for-profit business is allowed to operate in complete secrecy, they do what’s in THEIR best interest rather than that of their customers? I’m serious about that – secrecy is in their contracts. They don’t have to tell anyone anything, and the companies they work with aren’t allowed to tell anything to anybody either.

So that all makes sense, and it’s upsetting but not surprising. But here’s another issue. Remember how I mentioned “AWP” (average wholesale price) in passing? Originally, the “average wholesale price” was exactly what its name suggests. It was the average amount that a drug would cost to purchase from a wholesaler. Nobody knows when it changed, but it’s well known in the pharmacy business that AWP is a meaningless number. Supposedly it would be accurate if rebates and discounts didn’t exist and everything were left to the free market and manufacturers could charge what they wanted and what patients were willing to pay, but that’s not the world we live in. As a result, you might find that the AWP for a certain drug is $100, but the actual price from the wholesaler is $1. Or the AWP is $100, they charge the pharmacy $90, and then they give the PBM a $60 rebate. So why does that matter? Who cares what the AWP is when it’s not the actual price of the drug? Deductibles. Deductibles are why this grossly inflated number is important. Because until you meet your deductible (and again once you hit the “donut hole” if you’re on Medicare Part D), the cost that you pay is based on the AWP. It doesn’t matter that the drug actually cost the pharmacy $1, or if the manufacturer gave a $60 rebate. What matters is that the AWP is $100, and the insurance company is going to graciously negotiate a reduced copay for you of $95. How nice of them!

PBMs also have the power to create a formulary, which is a list of the drugs they will cover without requiring a special explanation from your doctor about why that exact medicine is required (also called a “prior authorization”). Some PBMs also have “tiers,” which means that drugs in one tier are preferred and have a lower copay for the patient, and drugs in a different tier are still covered, but at a higher copay. The point of this (the reason they give, anyway) is to encourage you to take less expensive medication whenever that’s an option. If a lower cost drug does the same thing as a higher cost drug, it makes sense that the insurance company would try to steer you toward the less expensive option. Sounds great. If everybody takes less expensive medications, then healthcare in general is less expensive for everyone.

Exceeeept…. lots of manufacturers want their drugs to be on a PBM’s formulary. They can (and do) buy their way onto a formulary. They buy their way into a better tier. They literally pay a PBM to make patients more likely to take a more expensive medication. And the PBM doesn’t care one way or the other, because they’re just funneling that money from the insurance company to the pharmacy, so if they get a nice kickback from a drug company then they’re going to take it. 100%. And they don’t have to pass any of it along to the health plan or the patient because it’s a secret. As long as nobody finds out how much they’re pocketing, they’re in the clear. This is not hypothetical, it’s fact.

I’ll add a disclaimer that PBMs report retaining an average of only 10% to 15% of the rebates they negotiate, and they pass the rest of the savings off to health plans. This, obviously, is all self-reported and unverifiable due to the complex arrangements and secrecy agreements. But maybe they’re right. How much of that rebate is being retained by the health plan? A good chunk. How much is actually saving you money? Pennies on the dollar.

Oh, and have you ever gotten a letter in the mail from your PBM saying something like “Drug XYZ is changing to a different tier next month! Call your doctor now and switch to drug ABC to continue paying a lower copay!” Yeah. Manufacturers offer additional rebates to PBMs when the number of prescriptions sold for a given drug exceeds a predetermined threshold. Tell me again how that’s supposed to save Americans money rather than lining the pockets of PBMs? Mm-hmm.

Oh, and get this – a standard clause in a PBM/manufacturer contract requires the manufacturer to pay an additional “processing fee” when they send a rebate. Raking in all that dough is hard work. It’s like if your employer payed you to drive to the bank to deposit your paycheck. Sounds nice.

I know I’m making it out to sound like PBMs are solely responsible for our effed up prescription system, but they’re just the catalyst that lead to the mess we have now. Because manufacturers have to pay off PBMs to be included on their formularies, they jack up the prices of their drugs. Because they jack up the prices, wholesalers don’t want to buy the drugs (wholesalers have a pretty low profit margin in the big scheme of things). To make purchasing their drugs more appealing, manufacturers actually pay wholesalers to buy their medications. Please, explain to me how on god’s green earth that makes any sense!? It’s called a “distribution service fee,” and it’s what the wholesaler charges the manufacturer for the “service” of buying their drugs (including the cost of inventory storage and distribution to pharmacies). What?

Pharmacies make secret (obviously) contracts with wholesalers to keep their pharmacies stocked with drugs, and they get some sort of undisclosed discount from what the wholesaler is charging everyone else. But.. do they? Who knows, because it’s all secret.

You’d think it wouldn’t be too hard to find out where all the money is going, right? Most PBMs are publicly traded companies, they file taxes, and all that jazz. But with the growing number and scale of “administrative fees” and “service fees,” it’s increasingly complex (nigh on impossible) for medical plans, patients, the government, or your average Joe Schmoe to assess whether the fees/rebates/discounts are being passed through to reduce overall medical costs, or if they’re contributing to increasing costs. What I can say is that The National Pharmaceutical Council recently conducted a study of employers’ perceptions of the value that PBMs provide. Over 65% said that PBMs lack transparency in how they make money, and around 50% felt that rebates contribute to misaligned incentives that put PBMs’ business interests before those of their patients. Another way of putting it: 2/3 of employers think their PBM is doing something fishy, and 1/2 think that PBMs are ripping them off.

I found a couple of excellent examples of where, exactly, the money goes when you buy a prescription. Keep in mind that both of these scenarios assume that the system works exactly as intended, the PBM is being 100% transparent and honest with the health plan, and all rebates and discounts (minus the agreed upon administration fees) are being passed back to the health plan so that premiums and copays can decrease. This is assuming the PBMs are NOT skimming off the top, or requiring that patients purchase a more expensive medication because it gives the PBM a better rebate.

This is the ideal situation for a patient who has met their deductible and is purchasing a $100 medication that has an AWP (made-up nonsense price) of $120. This is what happens when the system is working as intended. The insurance company is losing money, and the PBM is making money.
This is the ideal situation for a patient who has NOT reached their deductible yet, and is buying a $400 prescription with an AWP of $480. This is how it’s really supposed to work, without any deception or secrecy (at least between the health plan and PBM – this would never work if the patient knew what was going on).

That second example just makes me mad. And I guarantee you that this is an accurate example. The PBM will tell you that they’ve negotiated a lower copay for you. See? The AWP (the “retail price”) of the medication is $480, and they’ve negotiated a lower copay for you so that you only need to pay $408. Because you’re still working toward your deductible, the insurance company isn’t going to help you pay for your drugs. Thankfully, they’re still negotiating on your behalf to bring down the cost a bit. But did you notice that the insurance and PBM combined are MAKING $292.75 OFF OF YOUR PURCHASE?? If the manufacturer is willing to settle for $88, the wholesaler only wants $2, and the pharmacy is fine with making $25.25, then WHY ARE YOU PAYING $408??? If PBMs had a face I would punch it.

As prices increase because of this ridiculous system we’ve developed, insurance companies have raised deductibles, premiums and copays. I know mine has. Did you notice that the insurance company and PBM make WAY more money before you reach your deductible? Yeah. That’s intentional. So tell me again how manufacturers and/or pharmacies are responsible for outrageous prices and copays? Mm-hmm.

And now PBMs are merging like crazy to decrease competition. There are only 3 PBMs (Express Scripts, Optum, Caremark) that handle over 75% of prescription claims. Express Scripts merged with two other major PBMs in recent years, taking out some major competitors (Medco and Cigna). Optum is owned by the insurance company UnitedHealthcare, and is gradually acquiring a slew of physician groups and clinics throughout the country. Caremark is owned by the pharmacy chain CVS, and has recently acquired Aetna (another major PBM). All of these mergers and acquisitions have majorly reduced the competition, and it’s giving these companies an opportunity to double-dip. People talk a lot about “big pharma,” but in 2017 (the most recent reliable data I could find), the largest PBMs had a higher revenue than the largest pharmaceutical companies. For example, Express Scripts reported revenue of $100 billion, while the pharmaceutical giant Pfizer had a revenue of $52 billion.

In an ideal world, with full transparency and healthy competition, PBMs would be performing a valuable service. Using their larger purchasing power to negotiate lower costs for prescription drugs is a good thing. But as it exists today, the system isn’t designed to prioritize savings for patients. A big reason for this is that PBMs aren’t incentivized to negotiate for lower prices, but for higher rebates. Manufacturers have two options in our current system: lower the cost of their medication across the board, or raise the price of their drugs while increasing the rebate they provide to PBMs. Either way they make the same profit per prescription, but the latter option ensures that they get good positions on a formulary and more people take their medication. Guess which one they’re going to pick.

An excellent study from 2018 (link at the bottom) tracked AWP prices against net prices for insulin (the “cash price” they base your deductible on, versus how much the manufacturer actually makes). From 2002 to 2013, the cash price for insulin nearly tripled. If you take insulin, you probably felt it hard. However, the money the drug companies actually made on insulin during this same time period either increased modestly, or actually went down. So if you’re paying more, and the manufacturer isn’t getting more, where is that money going? Ding ding ding! PBMs.

The people are starting to get wise to PBMs, but it’s not enough. In March, my state (Wisconsin) established a law intended to hold PBMs accountable for rising prescription drug prices (Act 9). It sounds great, but I’ve read the bill and it’s not going to change anything. The bill claims to “protect patients from the powerful middlemen in the prescription supply chain by shining the bright light of transparency on their actions.” That was in the Governor’s press release – sounds great, but no. The only thing I saw in the bill that looked helpful was restricting a PBM’s claw back ability. Previously, a PBM could, at any time, zoink money back from a pharmacy for a claim they’ve already paid for. Claw backs were a major problem, because the PBM didn’t even need to give a good reason. They could just change their mind about something they paid for without needing to prove why they think a claim was paid incorrectly. Now, they at least have to give notice and give the pharmacy a chance to appeal first.

Manufacturer rebates are also (supposedly) going to become transparent, but not really. Starting in June, all PBMs will need to submit reports showing the aggregate rebate amount that they’ve received and retained from all pharmaceutical manufacturers for prescriptions sold in Wisconsin. Sounds great, except that they’re reporting this information annually to the Office of the Commissioner of Insurance (the government) rather than the actual patients who were affected, and they don’t have to break it down by drug or anything. So, yes, we’ll know how much they’re stealing from us every year, but you’ll have no idea if YOUR drug prices were affected.

This new law also prohibits PBM gag clauses on pharmacists! Yay! But, no, because I read the verbiage used in the law and it specifically says that a PBM can’t stop me from telling you what drug would be cheaper. That was never part of our gag order to begin with. So, yes, they’re doing something, but not anything that needed to be done.

It also limits how much a PBM can charge a patient for their medications! Yay! But, no, because it actually says that the PBM can’t charge a copay that’s greater than what the pharmacy would charge a patient who didn’t have insurance. They’re “fixing” a problem that doesn’t exist. So, there’s that.

I just want the bullshit to end, but it’s never going to so long as healthcare is a for-profit business. We can’t rely on PBMs to do what’s right, so we need to do everything we can to educate the public about what the problems are in our current system so that we can, some day, make it right. Are you with me?

References:
http://phrma-docs.phrma.org/files/dmfile/Follow-the-Dollar-Report.pdf https://www.statnews.com/2018/08/27/pharmacy-benefit-managers-good-or-bad/ https://jamanetwork.com/journals/jama/article-abstract/2678286 https://time.com/5564547/drug-prices-medicine/ https://www.congress.gov/115/plaws/publ263/PLAW-115publ263.pdf https://www.kff.org/medicare/issue-brief/how-does-prescription-drug-spending-and-use-compare-across-large-employer-plans-medicare-part-d-and-medicaid/ https://www.rand.org/pubs/research_reports/RR2956.html https://care.diabetesjournals.org/content/early/2018/05/03/dci18-0019

Getting Back Into the Swing of Things

I don’t know about you, but the past year has been HARD. Quarantine hasn’t affected my social life or anything (I didn’t have one before COVID, so no great loss there), but daaaaamn, these kids need to get out of my house. They love each other, I love them, obviously, but this “together 24/7” thing isn’t doing anyone any favors.

These Hilarious Cartoons Showcase the Reality of Distance Learning at Home  | Parents
Seriously? Every time. Every. Time.

In my area, school has been completely virtual since last March. They went back to in-person starting March 1st (4 days in person, 1 day virtual), but that only lasted 2 weeks. This past week was spring break, and next week is all virtual because they’re expecting people to do something stupid over spring break and get everyone sick (they’re not wrong). That 2 weeks of being child-free was just enough for me to remember what I’ve been missing. I got so much done! I wasn’t constantly bombarded with “mom mom mom” and got to actually finish tasks without (Hey mom, look at me!) having to (Hey, MOM! He hit me!) stop every 5 (Can I read you this story? Except that I don’t know how to read, but I really do, but I don’t want to read this) seconds to deal with (I’m so hungry, I need a snack nooowwww) their nonsense. It was fabulous.

30+ Mom Memes For All The Tired Moms Out There – theCHIVE :
Seriously, though.

I’ve been doing a lot of freelance writing lately, which is weird to think about. Like, people are actually giving me money to write stuff? What? I love it, but it’s so weird. I’ve been primarily ghost writing blog articles for a law firm in Philadelphia. They’ve finally realized I have a medical background, so now I get to write about things like premature births, anticoagulants, and radiology malpractice. It’s way more interesting than the property and product liability stuff they had me writing about in the beginning (yawn). I literally don’t even know how I got that job, but it’s steady work and I’m enjoying it.

I also did quite a bit of writing last month for a parenting app that has yet to be released. That was interesting. It’s apparently going to be an app that gives you ideas for developmentally appropriate activities to do with your baby or toddler. But, and this is my favorite part, they’re making it for parents like me. They gave me ideas as they’re typically presented to parents, and I got to write it in a way that would appeal to someone like me.

A typical parenting blog/app/guilt trip might read: “Offer your toddler 3 meals and at least 2 healthy snacks every day. Ensure that all food groups are offered, and encourage them to try at least one bite of each food you place before them. To help pique your child’s interest, use a variety of colorful foods to create a fun work of art on their plate!” Instead of that malarkey, I got to write things like: “There will be days when your kid turns up their nose at the food you’ve made in favor of the stale crushed crackers they find between the couch cushions. That’s okay, it happens. Offer healthy food whenever you’re able, and don’t sweat it if they turn it down and decide to go hungry. They won’t starve themselves.”

Think you're a bad mom? | Bad mom, Mommy humor, Mom humor
As long as you’re not throwing your child at predators, you’re probably good.

In unrelated news, I spent the last year memorizing the entire soundtrack from Hamilton (not, like, intentionally, it’s just been the only thing I want to listen to since it came out on Disney+). The only downside is that now Madeline will occasionally burst out into song. Why’s that a downside? Because you never know if she’s going to sing a random line from “Say No to This” in public (if you’ve seen it, you know why that’s less than ideal). But then sometimes she just belts out a “I’m young scrappy and hungry, and I’m not throwing away my shot!” and it’s all good again.

It’s been a hell of a year.

It’s been… a while since my last post, and for that I apologize. It’s been a busy couple of months! We’re going to recap the events of the past 2 months at warp speed, because that’s how fast it’s seemed to go by.

Halloween! To me, it’s always been a holiday for little kids. I like to make the kids’ costumes, but sometimes I don’t have time and we just buy one. Of course, the purchased costumes are expensive and fall apart after a couple of wears, so making one is usually my preference when I can. This year, COVID threw quite the wrench into things. Trick-or-treating was cancelled, and I wasn’t about to make them a costume to wear at home. So they just wore one from a previous year and we decided to have a party at home.

Scratch that, Madeline decided we’d have a party at home. An all day party. With a scavenger hunt. And all the decorations. And Halloween food. With Halloween cookies, and candy, and prizes. She made up her mind, and that was that. It’s hard to argue with a kid who’s been stuck inside since March.

I don’t really do parties, or decorations, or holidays that aren’t Christmas. Just not my thing. But it’s been such a dumpster fire of a year that I figured they needed something to lift their spirits. So we had a Halloween party. And it. was. epic.

I know that word gets thrown around a lot for non-epic events, but this was truly stupendous. Monumental, even. I made the best cookies I’ve ever made. I arranged party games, Halloween-themed meals and snacks, and stayed up way too late the night before filling goody bags with candy and decorating the kitchen and living room so they’d be surprised when they woke up. And we had an all day scavenger hunt. That was one of the most exhausting thing I’ve ever done. I’d give them clues to find a craft hidden somewhere in the house, they’d do the craft, and when they finished I’d give them a clue to find a gift bag filled with candy or a prize. It doesn’t sound like much, but we did this for hours. Literally hours. They loved it, and I never want to do it again. It might not have been so bad, but they’re terrible at clues so I didn’t want to hide everything beforehand or else they’d find everything right away. So I was running around the house during each activity trying to hide things in different places for the next round of clues. And Emmett can’t really do crafts on his own, so I was helping with that. And I still had to make the food. I’m not complaining – it was an amazing day – but, jeeze, never again.

Next was Emmett’s birthday! He’s 8 years old now. It’s crazy. He said he wanted a “beautiful chocolate cake,” so I decided to plan something amazing. Nothing could beat the cake I made for him last year, but I knew it would still be awesome.

Last year’s cake. It was a masterpiece of chocolate cake and delicious, homemade marshmallow fondant. I peaked too soon.

I was planning on some Great British Bake-Off level chocolate work. Ribbons, curls, straws, multiple colors, maybe some homemade chocolate candies, all tempered to give it a glossy shine. I was ready to make it amazing. Of course, Emmett’s birthday came just a few days before Thanksgiving this year, so I had that on my mind, too. I had more big plans for Thanksgiving – lots of cooking, baking, beautiful cookies…. but then we got COVID.

Let me start by saying that we wear masks everywhere. The kids are on board with masks, too. They think it sucks, which it does, but we wear them and silently judge anyone not wearing one in public. We don’t go out much – I work 2 days per week, I get groceries a little more often than every other week (ordinarily I go every other day), and we rarely venture out to go shopping. Even with all that, we got COVID. I blame my work, because it’s been spreading through employees like the plague.

You hear a lot about how most people are either asymptomatic or have symptoms like you would with the flu. Everybody with half a brain knows that the severe cases are a hell of a lot more severe than the flu, but mild cases are supposed to be manageable. Let me tell you, I’ve had the flu, and this was not it. We’re talking a fever, complete with terrible sweating and teeth-chattering chills for a full week, sleeping 18-20 hours per day, body aches and muscle spasms that made me cry, coughing to the point where you have trouble breathing any time you try to move for more than a couple of minutes, and feeling like I was going to pass out and/or throw up any time I tried to stand. I also lost my sense of smell, which was actually a blessing, because I couldn’t physically get myself into the shower.

Aaron also got it, and had basically the same symptoms as me except that his breathing was worse. We contemplated going to the hospital, but we weren’t sure who would drive. His oxygen level kept dipping, but it always came back up after a couple of minutes, so we stayed home and hoped for the best.

But then it was Emmett’s birthday. I was in some sort of fever-dream state, feeling like I would keel over at any minute, and Aaron kept saying, “I bet everything we own that you won’t be able to make a cake.” Because I have the same level of stubbornness and determination as the people who die climbing Everest, I informed him in no uncertain terms that there WOULD be a cake, and it would be BEAUTIFUL. I don’t actually remember making most of it, but it turned out alright. None of that boxed cake mix and jarred frosting for me. It was beautiful and delicious. Not quite my vision, but it served its purpose. Just imagine what it could have looked like if I was mentally present. Also, I managed to wrap his presents somehow, because despite what Aaron said I was NOT about to give my child his birthday presents in a plastic bag. And no, I did not have the ability to make dinner. My stubbornness did not extend that far. We had cake for dinner.

He was happy about it, and that’s all that really matters.

The kids mostly had to fend for themselves. We traded off who slept on the couch and who slept in the bed in case they required the presence of an adult, and we left the snack cabinet open so they could eat whatever they wanted. So it was mostly chips, granola bars and fruit snacks for about a week. We sometimes ordered food to be delivered, but then one of us had to get up to open the door. It was only sometimes worth the effort.

Thanksgiving didn’t really happen. We were starting to improve, but still not really capable of much. Thankfully, a good friend brought us an entire Thanksgiving dinner the following day that kept us going for several days.

Now it’s almost Christmas, and things are starting to look up. We got a tree (it’s a bit of a Charlie Brown tree, lots of open spaces, but that’s alright), we have a few decorations up, and our elf on the shelf has been hiding throughout the house, spying on the children. I’ve decided that we’re going big for Christmas. It’s not like we have anything else going on, and we need something to be happy about.

Oh, and the rabbit, Nibbles, is VERY excited that we brought in a giant stick for him to chew on. It even has the green bits! His favorite! I put up a fence around the tree, but he can still reach some of the branches if he stretches, and he takes every opportunity to do what he does best (nibble).

He thinks he’s so sneaky. I see you, rabbit.

Since my recovery, I’ve been working on a lot of projects. I’m still doing some freelance writing, still teaching online, and my business is still going (though that’s fallen a bit to the wayside with everything else going on). Virtual school for the kids is a perpetual challenge, but we fix problems as they come up (and then new ones come up – it’s this fun game they play of “who can frustrate Mom the most today”). But honestly, it’s not so bad. It sounds like Emmett may get to go back in-person in January at some point, so here’s hoping that doesn’t change.

And finally, for now, here’s the best picture I’ve taken in a long time. It snowed a few days ago (though “snowed” is giving it too much credit – it was more of a dusting that stuck), and Madeline somehow made this amazing snowman. It’s perfect, and 100% Madeline.

Just LOOK at its face. It’s everything that’s right with this world.

So now this is me, signing off for now, wishing you all a very happy Chrismasolsticehanukwanzakah.