EDITORIAL:
CVS Places Consumers at Risk of Harm, And is Destroying the Profession of Pharmacy! - PART 1
As much as I wish it wasn't true, I can't deny that CVS/Caremark/Aetna/Omnicare/etc. has become the most dominant and powerful force in health care! Its resources and influence far exceed those of all the national pharmacy organizations combined. One could even conclude that CVS is even more powerful than the government. When the government has information regarding illegal or otherwise inappropriate programs and actions of CVS, the corporation always has enough millions to obtain a settlement in which it is able to claim "no wrongdoing."
CVS has had an exceptional and unprecedented opportunity to greatly improve the quality and safety of health care and drug therapy for patients, to be a powerful advocate for the professional role of pharmacists, and to be a trusted and respected employer for its thousands of pharmacists, pharmacy technicians, and other employees. However, because of corporate greed and an obsession with even greater profits and pleasing shareholders, the programs and actions of CVS have had exactly the opposite consequences.
Consequences
The consequences include denying millions of consumers the counseling and other services that pharmacists are in a position to provide, thereby placing them at risk of serious adverse events and even death as a result of errors and other drug-related problems. The risk exists not only for consumers who use the huge network of CVS stores, but also for those who use its Caremark mail-order pharmacies and the thousands of other pharmacies who must participate in CVS/Caremark-administered prescription plans that compensate pharmacies below drug product cost or otherwise in amounts that are insufficient to provide needed services. With its ownership of one of the largest chain pharmacies, health insurance companies (Aetna), PBMs (Caremark), and long-term care pharmacies (Omnicare), CVS exerts vast power and influence not only within its own operations, but also on the other companies and individuals who must "compete" with the negative forces of the CVS entities.
A second consequence of the policies and decisions of CVS is the devaluation of the services pharmacists have the ability to provide. Community pharmacists are the face of the profession of pharmacy for the public. However, when CVS management-imposed metrics, quotas, staffing reductions, and harassment make it difficult for its pharmacists to even greet, let alone provide consultation for patients, its pharmacists have little or no time to communicate with patients. The result is that the knowledge and skills of pharmacists that should be applied for the benefit and safety of their patients are denied and essentially unknown to their patients. As one of the largest employers of pharmacists, CVS management suppression of the use and visibility of the knowledge of pharmacists devalues their abilities, damages the standards for pharmacy practice, and is destroying the role of pharmacists in assuring appropriate and safe drug therapy. This destructive impact is not limited to CVS stores, as inequitable CVS/Caremark programs impose economic and service-diminishing restraints on thousands of other pharmacies.
A third consequence of the policies and actions of CVS management is the destructive effect on the morale and performance of its own pharmacists and pharmacy technicians. I know of no other organization in which management is reviled and resented to the extent that it is at CVS. I do not seek out criticisms of CVS – they are forwarded to me by CVS pharmacists and others who know that I am concerned and sympathetic to their dilemma of demeaning and stressful working conditions in a position in which they must stay because employment elsewhere is not available. I do not participate on social media websites, in part because I can't keep up with emails, even in "retirement". However, many of the comments that do appear on those sites are forwarded to me, often in descriptive language that I don't condone and won't print. "Hate" is not an overstatement of the attitude of thousands of CVS employees toward its management, but they don't have options and they are trapped. If this is the situation that exists among the employees who best know the working conditions and their resultant risks for patients, the circumstances must be exposed and the public must be on guard for its own safety.
"Chaos at Chain Pharmacies"
On January 31, 2020, a bombshell investigative report was published in The New York Times (Ellen Gabler; page A1) titled, "Overloaded Pharmacists Warn They're Making Fatal Mistakes: How Chaos at Chain Pharmacies is Putting Patients at Risk." Ms. Gabler's very thorough investigations, interviews, and reporting include specific examples of errors, quotes from CVS and other chain pharmacists voicing concerns regarding working conditions and increased risks for errors, and interviews with concerned physicians and officials of medical associations and others. Because of fear of retaliation and being fired, at least one of the CVS pharmacists agreed to be interviewed only following assurance that his identity would not be revealed.
I urge you to read the entire story. Examples of specific comments of pharmacists and others that are included in the story are provided below:
"I am a danger to the public working for CVS." (Please also see my editorial in the May, 2019 issue of The Pharmacist Activist).
"We are afraid to speak up and lose our jobs. PLEASE HELP." (a response of a pharmacist to a Missouri Board of Pharmacy survey)
"(Pharmacists) struggle to fill prescriptions, give flu shots, tend the drive-through, answer phones, work the register, counsel patients and call doctors and insurance companies…all the while racing to meet corporate performance metrics that they characterized as unreasonable and unsafe in an industry squeezed to do more with less."
"My fellow pharmacists and pharmacy technicians are at our breaking point. Chain pharmacy practices are preventing us from taking care of our patients and putting them at risk of dangerous medication errors."
"Metrics put unnecessary pressure on pharmacy staff to fill prescriptions as fast as possible, resulting in errors."
"Any dissent perceived by corporate is met with a target placed on one's back."
"I certainly make more mistakes. I had two misfills in three years with the previous staffing and now I make 10-12 per year (that are caught)."
"We are forced to harass patients at checkout to fill unnecessary meds, request unnecessary refills, and to enroll in automatic fill programs that result in dangerous duplications and meds to be filled that were intended for single-time use."
"We are being asked to do things that we know at a gut level are dangerous. If we don't or can't do them, our employers will find someone else who will, and they will likely try to pay them less for the same work."
"I am expected to make 50-100 phone calls in addition to answering phone calls, consultations, vaccinations, and prescription verification. This has resulted in dispensing errors."
"Many unwanted refill requests are generated by automated systems designed in part to increase sales. Others were the result of phone calls from pharmacists, who said they faced pressure to reach quotas."
"…we are overwhelming doctors' office staff with constant calls, and patients are often kept on medication that is unneeded for extended periods of time."
(experience of a psychiatrist with concerns about recurring requests to prescribe 90-day supplies of medications) "He started stamping prescriptions, 'AT MONTHLY INTERVALS ONLY.' Despite those explicit instructions…he received faxes from CVS saying his patients had asked for – and been given – 90-day supplies. …it was a 'baldfaced lie' that the patients had asked for the medication, providing statements from patients saying as much. 'I am disgusted with this,' said the psychiatrist who worries that patients may attempt suicide with excess medication. 'There are going to be people dead only because they have enough medication to do the deed with.'"
"Patient safety is of utmost concern, with staffing carefully set to ensure accurate dispensing. Investment in technology such as e-prescribing has increased safety and efficiency. They (CVS and others) denied that pharmacists were under extreme pressure or faced reprisals."
"When a pharmacist has a legitimate concern about working conditions, we make every effort to address that concern in good faith."
"Errors, the companies said, are regrettable, but rare; they declined to provide data about mistakes."
(in response to the reporter's question about a CVS form for staff members to report errors that asks whether the patient is a "media threat"): "CVS said in a statement it would not provide details on what it called its 'escalation process.'"
(in response to the resignation of a pharmacist [Wesley Hickman in North Carolina who now runs an independent pharmacy] following a 13-hour shift as the only pharmacist who filled 552 prescriptions with no breaks for lunch or dinner): "CVS said it could not comment on the 'individual concerns' of a former employee."
(Editor's note: CVS knows exactly how many prescriptions were filled in that pharmacy that day. I have to think that if 552 prescriptions had not been filled, even 551 or 553, CVS would have accused the pharmacist of lying.)
"Metrics are meant to provide better patient care, not penalize pharmacists."
(in response to concerns about calls to patients and prescribers about 90-day supplies and automatic refills): "CVS says outreach to patients and doctors can help patients stay up-to-date on their medications, and lead to lower costs and better health." "CVS said it continued to 'refine and enhance' the program."
(in response to concerns about 90-day supplies of medications for patients with mental health problems): "CVS has created a system to address the issue."
CVS response to NYT article
The New York Times investigation and report clearly hit a nerve in CVS management. On the same date (January 31) the article was published, CVS issued a press release that includes the following comments; my Editor's notes/observations are added in parentheses:
CVS - "We fundamentally disagree with the recent assertion in The New York Times that patient safety is at risk in America's pharmacies."
(Editor's note: CVS must have anointed itself as America's pharmacy. The NYT investigation specifically applied to chain pharmacies, and primarily CVS.)
CVS - "Patient safety is our highest priority."
(Editor's note: As they say in the direct-to-consumer ads for prescription medications, "Your experience may vary." I will have more to say about this claim in Part 2 of this series.)
CVS - "Despite our excellent safety record, we are committed to continually improving. We've made important strides, including using technology to enhance accuracy, regularly measuring the quality of our pharmacy services and, most importantly, listening to and valuing the feedback of our pharmacists."
(Editor's advice: Pharmacists should have another job offer in hand prior to providing "feedback.")
CVS - "We are fierce advocates for expanding the number and role of pharmacy technicians at our stores. Qualified and trained pharmacy technicians allow pharmacists to have more time to provide patient care, answer questions about medications and serve as true health care counselors."… "As part of our continued commitment to safety and to supporting our pharmacy teams, CVS Health has been on the forefront of advocating for states to increase pharmacy technician to pharmacist ratios. By allowing additional pharmacy technicians behind the counter, we are able to ensure that we are safely and effectively filling prescriptions, and most importantly, that pharmacists are able to provide more effective patient care and counseling."
(Editor's note: In addition to closing "poor-performing" stores, CVS is reducing pharmacist hours and technician hours, a reality that can't be reconciled with its claims. Increasing pharmacy technician to pharmacist ratios is NOT the answer to safety concerns, and would only further add to the supervisory responsibilities and stress of pharmacists for whom "more time" will supposedly be provided. Many CVS pharmacists currently work numerous hours "off-the-clock" to finish basic responsibilities, and have little or no time to speak with patients.)
CVS - "Measurement = Improvement." "Quality health care must be safe, effective, and efficient for patients to achieve their best possible health outcomes, which is why we measure the quality of services our pharmacists provide. Accountability for our pharmacists is important."
(Editor's questions: I understand that "safe" and "effective" are criteria for quality health care, but what is the basis for CVS identifying "efficient" as a criterion, and what are the parameters for demonstrating efficiency? What are the specific "services" that pharmacists provide for which CVS measures quality? Counseling of patients? No! Potential allergic reactions identified and prevented? No! Intervention on behalf of a patient that results in a prescription that would place a patient at risk not being dispensed? No – unless it is a negative evaluation because one less prescription was dispensed and valuable time was consumed without any payment.)
CVS - "We constantly monitor prescription volume and make changes to our staffing levels as volume changes."
(Editor's question: Is it just a coincidence that the number of reductions in staffing levels is far greater than the number of increases in staffing levels?)
CVS - "We value the feedback of our pharmacists and take individual, legitimate concerns seriously."
(Editor's interpretation: "Management reserves the right to define "legitimate.")
CVS - "We have a firm non-retaliation policy in place for any employee, including our pharmacists, who want to voice a concern."
(Editor's interpretation: Management will not take action that might be viewed as retaliatory based on the specific concern a pharmacist identifies. However, it is often able to allege a violation of some obscure policy, or inefficiency because of advancing age to discipline or fire a pharmacist.)
CVS - "Last year, we conducted a survey of all of our pharmacists to gauge their perspective on the culture of patient safety in their pharmacies, and the overwhelming majority of responses were positive."
(Editor's note: Presumably management knows the identity of the pharmacist and the particular pharmacy for which survey responses are provided. Is it surprising that a majority of responses were positive when pharmacists anticipate that a negative response would result in management holding them responsible for the negative culture and impose disciplinary action?)
CVS - "There is no profession or industry that is immune from having dissatisfied employees."
(Editor's note: This statement is true, but it faults the employees who voice concerns and demeans the validity of concerns.")
CVS - "Another factor that indicates job satisfaction among CVS pharmacists is our extremely low turnover rate, which has decreased over the last 3 years."
(Editor's note: Other jobs for pharmacists are not available in many parts of the country. A current CVS pharmacist has provided the best response to management's flaunting a low turnover rate: "The turnover rate at CVS for pharmacists with another job offer is nearly 100%.")
Other responses
The New York Times article immediately went viral and has elicited thousands of responses from pharmacists, consumers, and many others. The CVS press release response has also resulted in many responses, primarily from CVS pharmacists and pharmacy technicians who are highly critical of CVS management for the lack of credibility of its "defense." Some of these comments, as well as my recommendations, will be included in Part 2 of this series in the March issue of The Pharmacist Activist.
As difficult as it is to have one's employer criticized in the media, common sentiments of CVS pharmacists and technicians have been encouragement and appreciation to reporter Ellen Gabler and the New York Times for the awareness, understanding, and communication of the risks for patients and the working conditions experienced by CVS employees. As one CVS pharmacist states: "Thank you for this article."
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