Wednesday, February 13, 2008

The Dark Side of Pharmacy Efficiency

Please read yesterday’s USA Today article Speed, High Volume Can Trigger Mistakes.

As I note in Pharmacy Profits & Part D, current reimbursement models are benefiting higher volume, more efficient pharmacies. This article asks: Will efficiency come at an unacceptable price?

The article links prescription errors at the two largest retail chains -- CVS Caremark (CVS) and Walgreens (WAG) -- to factors such as pharmacist workload, volume incentives for pharmacists, and a corporate emphasis on throughput. As background, you may want to look at my comparison from last July of average Weekly Prescriptions Per Pharmacy.

Why do I think this is a must-read article for all readers of Drug Channels?

  • It highlights the real human consequences underlying any breakdowns (preventable or not) in our system of pharmaceutical distribution.

  • The article gives time to both critics and defenders of high-volume pharmacy.

  • You may be motivated to examine your own prescriptions before swallowing a pill. (Walgreens actually has a very useful online Drug Information tool with pictures of specific pills.)

  • There is a very cool interactive graphic of a prescription’s path through the pharmacy.

Frustrated Pharmacists

I also encourage you to browse through the 250+ comments. Yes, an inevitable number of comments are either: (a) personal stories about dispensing errors, or (b) rants against corporations, the US healthcare system, pharmaceutical manufacturers, etc.

However, I also found many thought-provoking and troubling comments from pharmacists, most of whom feel frustrated by the current system. Here are some excerpts:

I worked as a retail pharmacist for a period of time and can tell you that when somebody drops off a prescription they always have two questions: How much is this going to cost and how long is it going to take? Most throw in real relevant questions like "Where is the motor oil and is it the motor oil that was in the sale flyer last week?"

Stories like this are difficult for me to read. I am very proud of my profession, and have been for the over 20 years I have practiced pharmacy. Yes, we do make mistakes. I have made mistakes myself. To those who seem to indicate that pharmacists do not care, you have no idea what you are talking about. Every mistake I have made has caused me anguish. Any mistake I make is one too many, but unfortunately I have not been able to be perfect. If you think a $500 fine would clear my conscience, you could not be further from the truth.

One of my biggest concerns as a pharmacist is trying to properly council a patient on their medication as they talk on their cell phone. I try to wait until they are done talking, but then some of them get upset that I am making them wait. Would you talk on your cell phone in your doctor's office as he or she examined you? I would not. I am not saying that this occurrence absolves the pharmacist from properly counciling a patient, just that the patient also has the responsibility to listen.

I am a pharmacist and I am sick of the public treating their local pharmacy like a fast food chain. They expect a prescription in minutes and expect perfection. People don't understand that these medications are DRUGS, with side effects. I agree that the profession does need a makeover and additional staffing. I have a Doctor of Pharmacy degree but I don't get enough time to actually talk to patients about their medication because I'm busy checking over 500 scripts a day.

I was constantly pressured into filling prescriptions faster. The statements from the drug executives about the pharmacist exercising "professional judgment" are a joke. These companies don't care about anything but the bottom line. I was not treated as a professional; I was treated like a machine that churned out prescriptions. The stress was unbearable. I constantly worried that I was going to kill somebody. The workload was impossible and the help was insufficient.

We expect our prescriptions to be delivered to us like fast food, handed to us in fifteen minutes or less out of a drive through window. I am a pharmacist and routinely face customers who become hostile when told that it may take half an hour or 45 minutes to fill their prescriptions. Everyone thinks that they are the only person when needs medicine and that the pharmacy staff should just work faster to help them out.

You can also read the perspectives of two pharmacist bloggers here and here.


  1. Adam, excellent posting, as usual. To me, this posting is screaming for eprescribing more than ever. If we really got eprescribing to work not only would it address the time to fill issue but it could even feed back the cost so the doctor and patient could make informed decisions based on alternatives, solving the other question...cost.

    Then I could find the motor oil that was on sale!


  2. If one were using total quality management techniques to manage the process one of the conclusions you would quickly come to is that errors could be reduced simply by eliminating some of the variables in the process. One that clearly stands out involves the pharmacist taking capsules or tablets out of one bottle, counting them and putting them into another bottle. Significant time could be saved by packaging in typical unit of prescription sizes. Medicines used to treat chronic conditions could be packaged in bottles containing a 30 day supply. Blister packaging or small bottles could be used for antibiotics and such that have a shortened dosing regimen. Doing so would reduce time and cost at the pharmacy while manufacturers cost could at least be offset by rationalization in package sizes. Another benefit to manufacturers and patients could be increased patient compliance. Think birth control packaging.

  3. The "fog of war" in pharmacies is actually the "fog of PBM messaging". Minute by minute we get
    messages of drug interactions which are well below any threshold of clinical significance. Add to that the incessant explanations needed address questions of copays,
    prior auths, step therapies and deductibles. A pharmacists job is stressful. I own a community pharmacy, staff it well with CPHTs and have added several levels of robotics and workflow scanning to assure accuracy. It's still a bear.
    Assuring 100% accuracy in this environment is the goal. Will the "fog of pharmacy" create errors? Unfortunately, yes. I shudder at the risks every day.

  4. USA Today has a follow-up story in today's paper about the role of pharmacy technicians: Drugstore chains rely on pharmacy technicians.


  5. Those chain stores that have made business vs professional decisions of 4 dollar generic prescriptions or FREE pushed our profession down an even darker spiral. Give credit to those chains that held their ground and seek a more reasonable price for their dispensing services. We have made the profession the same type of commodity that we have made generics a commodity. State boards of pharmacy need to step in aggressively because driving volume to these pharmacies by "giving" away services will only drive errors and ultimately those pharmacists that provide the services required by those laws will be driven out of business by those "big box" or combo operations that seek to sell higher marging private label products and use pharmacy as a loss leader. The question I ask, if this were your business would you give away $4 prescriptions or free and still expect to stay in business? We have reached a point of insanity with this. What does $4 or free tell our political folks when it comes to reimbursement?......

  6. One thing that escapes notice is Walmart. When I started with Walmart, the focus was on good service. There was enough staffing and the emphasis was on building a loyal clientel.

    When Walmart went to the $4 prescription plan, staffing levels were predictably cut. Now the service level has declined considerably. Most of the Walmarts I have worked at lately are falling apart. Wait times have increased dramatically, third party issues go unprocessed (which means people are not getting the drugs they need), and yes mistakes have gone up. I know of several mistakes that have happened over the last 6 months.

    Remember, you can't get something for nothing. Walmart and the chains get higher profits, but the price was lower quality care.