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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.

  • I have been a Retail Pharmacist for 22 years. Luckily my husband is an attorney and I know my rights. At the end of the day it is your license. Never allow a third party to interfere with your ability to practice pharmaceutical care. Document everything. Most of these upper managers are barely educated and have degrees that aren’t even close to business or healthcare. I think it is a crime and a public safety risk for them to continue to invent new checklists and metrics when they have zero understanding of how pharmacists think. This is an obvious conflict of interest business that focuses on quantity not quality. It is time for us to form a federal union like the pharmacists in England.

  • Scott;

    In all practices of pharmacy no where do we impact patients more than at the point of sale in retail, that statement comes from experience as Director and Owner for retail, LTC, home infusion, specialty and hospital pharmacy. For profit and not-for-profit. Your last statement, “Pharmacists …That’s exactly what pharmacists do in health systems like the Cleveland Clinic…Community pharmacists want to do this kind of work…” is similar to many pharmacists and healthcare professionals that work for large hospital systems arrogantly proclaim. The term, “for profit”, is used like its a bad thing. Your statement assumes a higher moral superiority. That’s not the case. In fact my ‘for profit’ entities have a much higher % of indigent and medicaid population because the ‘not for profit’ entities around us, ‘dump’ these payor sources on us. For profit are tax paying, productive members of the communities in which operate. Is Cleveland Clinic ‘not for profit’? If so then you do not pay federal, state taxes or property tax. In fact, many not for profit entities don’t even pay federal unemployment tax. Also; are you a 340b entity? IF so then you can’t compare what you do to any retailer. In fact that ‘for profit’ entity is starting out 30%+ gross margin behind you. You are being subsidized by the tax payers of the US, Ohio and Cleveland. You are also being subsidized by the large Pharma manufacturers that have to give up 20, 30, 40, 50% of their margin that fuels the 340b. Its complicated all right. Retail pharmacies run their business much more efficiently than you and I but still can’t dream to make the margins you do. We are all right there with you Scott; how do we allow these pharmacies the margins you get so that they can “end the era of high volume and speed. And…build incentives — and disincentives — into the pharmacy care delivery model…so that they too can be rewarded to uphold high practice standards and not be punished by cutting corners around safety and quality…” In Canada the federal government artificially holds generics at higher prices and name brands lower; pharmacies make good margins on both. Here a 30 day of multi-source generic can adjudicate at a negative number. How are US consumers going to accept higher prices for generic when they’ve already been told its too expensive. How can we drop the price of name brand when they are already giving up margin to every governmental agency as well as the 340b. And they are the innovators, they have discovered the medications that reduce mortality and morbidity. They created the pharmacist career. The answer is much more complicated then even you think.

  • Pharmacy Schools doubled, B- students now get accepted. There is a pharmacist surplus where supply exceeds demand. The chain pharmacies know pharmacists are a dime a dozen. Pharmacy Schools now advertise their PharmD programs on Facebook. You don’t like the working conditions? Quit. That is the reality of our profession.

  • Why is that no one is mentioning UNIONS? Why is it that the state governments have to PASS A LAW to allow pharmacists to eat? Individual pharmacists are powerless and retail pharmacy chains exploit this just like Henry Ford exploited his workforce before the union was created to fight fire with fire. A single voice of a powerful union that can bring a company to its knees is really the only way to force change. President Trump is right to say to always negotiate FROM A POSITION OF STRENGTH! I am an unemployed pharmacist because I spoke up and all of my colleagues are terrified of losing their jobs.

  • I once heard that compounding and pill counting is peculiar to small scale American pharmacies, and that in Europe this is done at larger manufacturing plants. Is this true, and why would this be the case? Naively, I’d think packaging everything with machines at large facilities would naturally lend greater quality control and economies of scale. Why do American pharmacists do things by hand? Which laws or market forces shape this?

  • “We must end the era of high volume and speed.”
    Dude, no.
    High volume and speed bring costs and prices down. What you are looking for are patient protections. We already have this: tort law. If a patient is injured due to negligence, they can sue. This threat keeps pharmacies on their toes.

    • People get the flu vaccine because they know they’ll get sick if they don’t. Same thing here, it’s deterrence. Pharmacies reduce mistakes to avoid liabilities. This is why doctors spend so much time thinking about and preventing malpractice suits.

      The author wrongly indicts speed, not sloppiness. We could reduce traffic fatalities by instituting a national 10kph speed limit, but that would suck.

    • Dude, yes. On every Pharmacy Permit there is the name of one hapless RPh who is forced to accept the full legal responsibility for the mess his employer has created and for which he has no power to fix. Imagine a world where the Physician is required to singlehandedly diagnose and treat everyone who walks through the door within 15 minutes or be disciplined regardless of how many patients walk in and how complicated their conditions are. No problem, the patient can sue if their outcome is not positive.

    • Dude, yes. Pharmacists are already on their toes working hour shifts with no break. When a patient is injured, the pharmacist, not the pharmacy gets sued. When a pharmacist does not meet the corporate metrics, they in danger of job loss. Open to constructive suggestions here.

    • I made two bland points: (1) slowing something down is not the only (and often not the best) way to make it safer (2) legal liability makes pharmacists take responsibility for accuracy. I don’t think any of these comments have refuted these points.

      @Craig Physicians are quite hurried, and patients can sue physicians for malpractice (not because their outcome is not positive). This keeps error rates in check- just as with pharmacists. Is there a difference?

      @ Kathy You describe a necessary and healthy tension that exists in any profession. If there is no pressure on accuracy, the work is no good (liability/fired). If there is no pressure on speed and volume, the work is too expensive (lose customer/fired). Is there a job where this isn’t the case?

      @TGBS Let us know if points 1 or 2 are incorrect.

  • Changes, such as what the Nursing Profession undertook, happen at the legislative level. And it requires Pharmcists knowledgeable in the legislative process of advocacy, and that has to begin in Pharmacy Schools. Some schools, such as Temple School of Pharmacy actually had an elective that did just that.
    In order to be effective that type of course should be in all Pharmacy Schools and be a required “elective”.

    • Re to Craig:

      Regarding doctors timeframe & being penalized…. That’s what the HCAPH scores do by taking money away for frowning faces, not to mention that patients have figured this out-esp if they are on Medicaid/Medicare – and they use it to get opioids that they want when they go to the ER because they know that the doc can’t afford to lose more money by getting a 🙁

  • Scott Knoer is well-suited for his next role as CEO and EVP of the American Pharmacists Association. Together we have learned we will influence policies and support changes by incentivizing the outcomes we seek.

  • I think this piece is short on solutions and facts. Cleveland Clinic pumps out more Rxs than most. If more pills do not equate to more care, why does Scott write one thing, but demand another in his own shop? Who is paying for all those shiny new buildings and robots that Cleveland has anyway? The margins on infused drugs is obscene and I don’t believe anyone is pointing that out to Scott or pressuring him to lower those rates. It’s good for him that health plans, employers, and patients are not rioting in front of their cancer centers or his specialty pharmacy. He would not have real solutions or facts on his side. Maybe APhA can show us the way.

    • Robert you are entirely correct; the oncolytics alone through Cleveland Clinics 340b would make you blush. Some gross margins are 80%. This program was originally designed for rural, critical access hospitals/clinics/health centers with poor and working poor not able to get medications. Why don’t hospital CEO’s talk about the 340b. Why doesn’t one EVER see a for profit private oncology/hematology practice any longer? Why aren’t patients given a choice as to where they get their treatments and in what setting? The answer is the 340b is making absurd amounts; hospitals can buy out oncologists at a number they can only imagine, THEN get paid a salary set for a king. All on the back of the manufacturers. For profit oncology practices can’t compete. Sales are transferred from a for profit, tax paying productive entity to a not for profit, unproductive entity. Outside of government, hospitals are the least productive business models.

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