The news that chaos reigns inside chain pharmacies, putting patients at risk, may have come as a shock to readers but it’s no surprise to any pharmacist, pharmacy technician, or pharmacy student, all of whom know that the system is broken.
Ellen Gabler’s exposé in the New York Times showed how big chain pharmacies sacrifice patient safety by placing unreasonable volume and speed demands on pharmacists. It highlighted how pharmacy staff are under-resourced, over-worked, and discouraged from speaking out about conditions they feel are putting patients in harm’s way.
Intense financial pressure combined with the volume-based reimbursement that drive the constant push for more pills are compromising patient care and pharmacist well-being. The payment model for medications is damaged beyond repair and must rebuilt from the ground up to ensure that all prescriptions are filled correctly and safely.
As the chief pharmacy officer for the Cleveland Clinic, I’ve spent the last nine years working to care for patients in our hospitals, clinics, family health centers, and 20 community pharmacies.
Our teams are held to exceptionally high standards, with a multitude of payer contracts that grade our overall health system on its performance and quality and put the organization’s revenue at risk when we drop the ball or achieve poor outcomes like high readmission rates. While these value-based payment models are works in progress that need to be perfected over time, they represent an important philosophical concept that patients are better served when the system pays for a desired outcome instead of the completion of a service or transaction.
Large for-profit pharmacies operate with a different set of expectations and standards. The vast majority of their pharmacy revenue streams are predicated on filling prescriptions. The payment system asks pharmacies for little more than “Did you fill it?”
It’s no wonder, then, that in order to make more money you have to fill more prescriptions — and bigger profits can be generated by filling them faster and faster. As the need for speed increases, quality, error rates, customer service, and outcomes decline. But no one is tracking these metrics.
This drives up health care costs as patients take the wrong medications or incorrect doses of the right ones, or take unnecessary and duplicate medications, or those with harmful drug-drug interactions — all things a careful pharmacist can detect beforehand.
Declining quality or safety don’t bother many members of the drug supply chain. They are tickled pink with this. More pills equal more cash for them.
The prescription drug supply chain and payment system are a mess. Pharmacists, who graduate as Doctors of Pharmacy after intense didactic and experiential training, are stuck in the middle of this profit-before-all-else racket — along with the patients they serve.
Pharmaceutical manufacturers, wholesalers, pharmacies, pharmacy benefit managers, insurance companies, and others have created a system that is distorted, opaque, and working against the interests of patients. The enormity of the problem leaves many of my pharmacist colleagues feeling helpless.
While there is a litany of complicated issues that must be addressed across the prescription drug supply chain, the most immediate one is delivering safe, high-quality medicines to patients. This is what pharmacists are trained to do but, as the Times showed, the industry in which they practice is taking shortcuts that compromise their ability to do what they went to school for. And it puts their patients in harm’s way.
Pharmacists need to take back control of their profession from those who seek to exploit their talents to merely pump out more pills and drive short-term quarterly earnings.
Pharmacists have the skills to improve transitions of care from hospitals to home, maximize drug therapy regimens, add value to the health care team, and actively manage diseases like diabetes and high blood pressure by monitoring patients and changing and adjusting their medications. That’s exactly what pharmacists do in health systems like the Cleveland Clinic, Geisinger Clinic, the Veterans Health Administration, and Kaiser Permanente, to name a few. Community pharmacists want to do this kind of work, but often aren’t allowed to do much more than fill prescriptions as fast as they can.
Solving the problems in pharmacy should start by elevating the role of pharmacists from one resembling fast food workers to the clinical, patient-focused positions they trained for and dedicate their professional lives to. We must end the era of high volume and speed. And we must build incentives — and disincentives — into the pharmacy care delivery model that reward those who uphold high practice standards and punish those who cut corners around safety and quality.
Fixing this mess will take serious policy changes. Pharmacists need to be the driving force to make them happen.
Scott Knoer, Pharm.D., is the chief pharmacy officer of the Cleveland Clinic.