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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.

  • A pharmacist’s role needs to recognized at ALL aspects of dispensing a prescription! Ancillary Services must also be recognized, but that’s another avenue that’s already being exploited! The bench marks are unrealistic to achieve, as doctors cannot be forced to (for example) place a statin on a patient’s regimen. These end up as a Negative performance. The PBM’s engage in automatic mailorder refills to drive performance, which leads to Waste, Fraud & Abuse. Pharmacist’s need: a minimum FEE for service per prescription ( we automatically provide our expertise) and the patient shops where they get the Best Service. The “preferred network” needs transparency, because that’s where PBM’s pay THEIR pharmacies, mailorder pharmacies and affiliates (and themselves) unfairly through “spread pricing” and discriminatory reimbursements. This is Collusion & Conspiracy! PBM transparency & oversight along with reform is the answer! These trillion dollar companies are outpacing and outthinking any changes on the horizon. Clinical and ancillary services are ADDITIONAL services that some pharmacies may provide. To move the payment scale to these services and away from the dispensing services is a mistake. All services need to be recognized & paid fairly!

  • This article is generalized, lacks specific pathways to solutions, and fails to identify the real source of the deterioration in retail. (But congrats on pumping your near-perfection health system in the beginning!). Retail-pharmacy-land is FAR beyond the point of just “pharmacists taking back the profession” and/or “pharmacists being the driving force to change” (wow, sounds so simple!) from the multi-BILLION dollar corporations that have million dollar lawyers who will sustain this environment, regardless of any kind-hearted suggestions of change. Corporate continues to cut hours, cut budgets, all while dramatically increasing volume and workload… even as customer complaints about the decline in service stream in. They do not care. They have created monopolies and established contracts with PBMs that force patients to use specific retail-chains, effectively killing competition and the notion of improving service for customer retainment. No pharmacist or pharmacist-led group can take on these massive giants without fear of losing their job to the next in line willing to jump in the flames. They need HELP. Unfortunately, and sadly, the only path to change now is more NYT-like articles and increased social media shaming, which would hopefully lead to public recognition/outrage, and politician-led law creations that FORCE real changes to come about. Until then, it’s all wishful thinking, and we’ll continue to watch as the retail-side of this profession burns.

  • For all intents and and purposes the big three (walmart, walgreen, cvs) control the retail drug market. They pretend to compete among themselves, but they aggressively crush competition. and buy out any independents they can. Likewise the big three wholesalers (Mckesson, Cardinal, Amerisource) control the wholesale market. Bottom line is that there is no longer any competition. Together they have destroyed the profession of pharmacy, and turned the profession into just providing a commodity. Now that there are enough pharmacists to meet the job openings, just watch them continue to destroy the profession, and watch our salaries drop. Walmart district pharmacists are now telling store pharmacists to shut up and be glad they have a job… and this is just the beginning.

  • I would love to see the Pharmacist be more in charge of the control of my medication. Doctors have so many patients, they can’t track everyone. Some of us fall by the wayside. There has been times, I don’t think I need to be talking as much as the Dr prescribed, and sometimes, I feel that I need more. This would be able to make this happen.

  • This is an interesting. article. Some of the areas that the author touches on aren’t entirely correct. There are safety nets in place to catch duplicate therapies and harmful adverse drug – drug interactions. This technology has been around for sveral decades and there are metrics that check for accuracy and safety, NOT just speed. YES, there are many challenges facing the pharmacy staff members and team such as good time management. adequate inventory and correct pharmacist-to- technician ratio that all affect counseling, customer service and safety. Measuring outcomes might be effective in a hospital or ambulatory settings but I am not certain how much this will reduce admission for patients with debilitating illnesses that require hospital interventions. Good read.

  • Pharmacy schools continue to graduate class after class of students carrying debt that they expected to pay off with a six figure salary only to struggle to find a job in an overcrowded labor market. The jobs that are available are high volume retail giants that won’t pay for 40 hour work weeks. Pharmacists don’t get enough technicians staffed to assist them, and double coverage of pharmacists only exists in the busiest of locations, which means the pharmacist can’t take a break for a meal because the pharmacy would have to close. All too often pharmacists come in early and stay late, further extending their shift lengths with no additional compensation. Paid hours keep getting cut as the large national retailers continue to drive local pharmacies out of business driving more volume towards the big name chains.
    It seems like the problem is starting to get a little more attention, but what is the pharmacist to do to drive this change?
    I applaud the effort of this article, and the recent Times article, to shed light on the issue, but the pharmacist has no control over these conditions. Policy changes will need to be made at a higher level to give some relief to these overworked professionals.

  • I totally agree, as an uprising pharmacist in a couple of months it’s really sad to say that we are looked at especially at retail chains as pill pushers and all our clinical knowledge and skills are not appreciated

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