Thursday, October 08, 2009

A Phony Mail Order Controversy

Are consumers satisfied with mail-order pharmacies?

The J.D. Power and Associates 2009 National Pharmacy Study shows high average satisfaction at mail-order pharmacies. Yet the National Community Pharmacists Association (NCPA) issued a press release immediately after the J.D. Power results claiming Patient Survey Finds Widespread Problems With Mail Order Pharmacies.

Drug Topics magazine duly reported on the “controversy” of these supposedly “conflicting results.”

Now, I don't want to get off on a rant here, but it’s inaccurate and intellectually dishonest to compare the NCPA’s aggregation of “just over 400” independent pharmacy customers' viewpoints with J.D. Power’s statistically sound survey of 12,215 pharmacy customers. And I will gladly debate any pharmacy school professor who wants to defend the statistical reliability of NCPA’s methodology.


Here are the average pharmacy satisfaction rankings rankings (out of 1,000 points) by pharmacy format from the J.D. Power survey. Click the chart to enlarge it. Note that brick-and-mortar pharmacies were evaluated using different, store-related factors than mail-order pharmacies. (See paragraph 6 of the J.D. Power press release for details.)

Two interesting findings:
  • The mail-order pharmacies of the big 3 pharmacy benefit managers (PBMs)—CVS Caremark (CVS), Express Scripts (ESRX), and Medco Health Solutions (MHS)—all ranked slightly below the mail-order average.

  • Two franchise chains of independent pharmacies—Health Mart (McKesson) and Medicine Shoppe (Cardinal Health)—ranked above the chain segment average.
The J.D. Power results are consistent with the relatively high mail satisfaction findings from the 2008 Boehringer Ingelheim Pharmacy Satisfaction Digest (conducted by WilsonRx) that I discuss in Pharmacists Can't Get No Satisfaction from Mail.


Gosh, how did the combined efforts of J.D. Power and WilsonRx fail to detect the supposed "widespread problems" with mail order?

A quick look at the respective methodologies makes the answer crystal clear. Click the table to enlarge it.
The NCPA survey suffers from what statisticians call “bias”—the tendency for a survey’s findings to be unrepresentative of the whole population. Sources of bias include:
  • Non-response bias: Only consumers who shop at independent pharmacies were sampled.

  • Invalid sample size: “Just over 400” surveys collected from more than 23,000 NCPA member pharmacies

  • Non-sampling error: Did the pharmacy owners encourage only disgruntled consumers to fill out the survey? Who decided which surveys got returned for analysis?
I could go on, but you get the idea.

Look, I understand that some pharmacists don’t like mail-order because it hurts their business. But it’s insulting to the discipline of statistics to place NCPA’s survey side-by-side with the other two surveys.

Before you accuse me of bias, keep in mind that I am ranting about statistics, not about mail-order pharmacies. If you are still confused, please read Chapter 4 of What is a Survey?, a straightforward, non-technical booklet designed to improve survey literacy.

Of course, that's just my opinion. I could be wrong.


  1. Adam, You, NCPA,Pharmacies, and JD Powers, incorrectly define customer in your survey and articles. A customer is one who BUYS goods and services. What you call a customer is a consumer and at best a patient, the consumer in >90% of mail order users is a fully funded health insurance plan. Take a survey of the fully funded plans and their thoughts on paying $154.00 for a metformin Rx that sells for $9.95 retail and you will better understand the WG + Wal-mart direct to consumer concept.
    Jim Fields ApproRx

  2. Jim,

    You make a good point. However, all of these studies attempt to look at the consumer (not payer) experience. If co-pays are equal across brick-and-mortar alternatives, then convenience and "consumer satisfaction" will influence where a script gets filled.

    In the future, I expect to see more preferred and restricted networks, which will reduce the relevance of satisfaction studies. See my new report for details.


  3. I will never argue statistics with you. If I ever do, pls refer me to today's post. :)

  4. So you bash independents again by looking the survey? You are ignoring the problems with mail order that my customers tell me about every day.

  5. Adam-

    I hate to admit it but you make a good point about the NCPA survey. My real question is why doesn't NCPA conduct a good survey to show the benefits of community pharmacy over mail.
    1. Counseling
    2. Reminders to refill and availability when people forget
    3. Delivery and handling is more secure
    4. Personal service

    The pbms control mail order so they can force people to use it even if the patient outcomes and service are worse. We need to tell the other side of our story in the right way.


  6. So, JD Power found that patients were more satisfied with independent community pharmacies such as Health Mart and the Medicine Shoppe than mail order. And, according to JD Power, patients gave the big three PBMs (CVS Caremark, Express Scripts and Medco) mediocre mail-order ratings. Meanwhile, NCPA reports hearing complaints from patients about mail order, such as late delivery (sometimes forcing double payment for an emergency fill at a local pharmacy), misdelivery and safety concerns (extreme temperatures, etc.). Exactly what are we supposed to be worked up about here?

    Experience also shows room for concern. More than 30 state attorneys general in the last five years filed lawsuits alleging PBM abuses, securing $370 million in restitution. Two former mail order pharmacists in Hunt/Gauger vs Merck/Merck-Medco had alleged that when a prescription wasn’t filled on time they would be ordered by superiors to destroy the script and any associated paperwork to hide the evidence. This is in addition to their allegations that the PBM had delivered medications without ensuring that the correct dosage, strength, or quantity was being dispensed.

    For more patient views, check out the reader posts in response to the’s story on this subject. There’s legitimate concern from patients and plenty of reason to reject mandatory mail-order programs. It’s simply not for everyone.

  7. I just have one question? If mail service pharmacy is so well loved by the consumer why do PBMs design the plans to force or financially coerce consumers to use the PBM owned mail service pharmacy. And why does the PBM industry fight mail order parity legislation that gives the consumer the choice. We all know the answer Adam, and so do you.

  8. Adam:

    Another fun and insightful way to look at the Mail Order/NACDS issue is the spin that comes from the PR folks, even when the data is valid.

    My favorite current example is the Allstate ad that says that “What would you say if I told you that Geico customers who switched to Allstate save an average of $473 dollars?” The appropriate answer is not “No way” like in the ad, but “of course; only the people with big savings changed insurers; the people who didn’t save much, or who got a higher quote from Allstate stayed with Geico…” – big “duh” here. There is certainly a subset of Allstate customers who saved and made the move in the opposite direction. I suppose that some people with both companies moved in ways that did not advantage them economically, but that is a different story.

    John Paulos at Temple has offered a number of illuminating examples. I’d recommend the following leisure reading:

    Innumeracy: Mathematical Illiteracy and Its Consequences

    A Mathematician Reads the Newspaper

  9. Adam, as usual, you’re spot on. Looking at the dispensing of prescriptions from a supply chain perspective, mail order makes perfect sense. It’s cheaper, less error prone and much more efficient. But the issue that bedevils both retail pharmacy and industry observers such as me is that the large PBMs use the leverage they have as both manager and provider to tilt the playing field in their direction. All too often the PBMs, through their Byzantine pricing and marketing practices, take financial advantage of the health plan sponsors, the retail pharmacies and recipients. If they were properly regulated and forced into true transparency, much of this would cease. To be sure, if and when that happens, many plans and recipients will still prefer the use of home delivery, but the decisions will be based on convenience and true economics, rather than the shell game that now occurs.


  10. To John Norton,

    Thanks for commenting. For those who don't know, John is Associate Director, Public Relations, at NCPA.

    I looked at the comments on the Washington Post site. The second comment echoes my comments about the reliability of NCPA's release and Drug Topics' article:

    "It's pretty poor -- and biased -- journalism to ADMIT that a study was performed by a group that has an economic stake in finding poor service from mail-order pharmacies -- and which was not professionally performed in any event -- and then use that for an article recounting (and requesting) horror stories about such pharmacies."

    My post is about the misuse of statistics, not about the alleged evils of PBMs.


  11. John is an example of the wingnut mentality that is all to prevalent at NCPA. I am a strong advocate for independent pharmacy and work in this industry. Independent pharmacy needs to beat PBMs by promoting all the things that make independent pharmacy better than mail or chains for that matter, such as personalized service, doing a better job answering questions, faster, friendlier service. NCPA is unknown to almost all consumers and wastes their money on crap studies like this one. Its a disservice to independents and the public who probably won't ever see it anyways (which is why PBMs are not exactly quaking in their boots).

  12. Are you making a Dennis Miller reference about rants? I loved him before he became a right-wing nut job.

  13. YES! Thank you for noticing. I actually used his exact language at the beginning and end of my post.

    I agree that he used to be much funnier. I'd take Miller over Maher on HBO Friday nights any time.


  14. Adam

    They are measuring customer Satisfaction. But it would be interesting to know what NDC's the PBM MAIL ORDERS bill –vs- the NDC's that independent pharmacies billing.

    As you know the three largest PBMs have their own mail order, and they bill themselves and pay themselves, and they accept contracts ranging from accept AWP-35% + $ 0.00 dispensing fee for the mail order that they own. Contradiction? NO

    PBM Mail Order are using BRAND REPACK NDC’s and they are billing and charging the Plan Sponsor the same product at a higher price.

    Is there any study showing how the PBM Mail Order rips off the Plan Sponsors by charging them more and making them (Plan Sponsor) believe they are paying less?

    “Such is Life”

  15. How did JD Power collect survey answers? Seems to me I saw/read/heard something about their surveys being consumer-initiated; that is, consumers would choose to participate by going to the web-site or what-have-you and registering their opinion.

    If the mail order pharmacies sent out a flier with each delivery encouraging consumers to participate in the survey (rather than a polling company randomly contacting consumers), that might tend to skew the results, wouldn't it?

    Probably not as much as the NCPA survey, but still...

    And retail pharmacists probably wouldn't be nearly as ticked off at mail order pharmacies if they didn't make it so doggone difficult for us to dispense a "hold-over" supply for the patients whose mail order supply hasn't shown up yet.

    Tom Connelly, RPh
    Rising Sun, MD

  16. It would seem that many readers missed the point. Adam does not "bash independents" or claim that "mail service pharmacy is so well loved." The purpose of this article is to examine the methodology of NCPA's survey. Even if the findings are correct, they carry little weight because of the poor data-gathering process.