EDITORIAL:
A CVS story (continued)
In the September issue of The Pharmacist Activist, I provided the first part of "A CVS story" that a current long-term CVS pharmacist shared with me. His story continues below:
"Let's say I fill your prescription for olmesartan 40 mg #90 for a 90-day supply. In about 64 days the CVS computer will automatically refill another 90-day supply. I guarantee this will happen WITHOUT your consent. Why? Because the technician who gave you the first prescription will press the display to enroll you in "Ready-Fill" without asking for your permission. It's just another metric in a day at CVS. Even if refills were NOT authorized on the original prescription, the CVS pharmacy computer system "Rx-Net" will send an electronic request to your prescriber on about day 64 for it to be renewed. The staff at your prescriber's office renews it without consulting the prescriber. It comes back to the pharmacy as an authorized Rx sent in by your prescriber and gets filled. Now, since you still have medication in your home that will last more than 3 weeks CVS will send you robocalls and automated text messages to come in to pick up your prescription. After 14 days, it is required that all prescriptions not picked up by patients be Returned to Stock (RTS). So the technicians every day put back more than 100 prescriptions and reverse the claims. So now we are out to about day 78 when the RTS is done. Another week goes by and you now notice there are only about 5 tablets remaining in the prescription vial. You recall the automated texts and the robocalls so you drive to CVS to pick up your prescription before you run out of medicine. Guess what I get to tell you! It's not ready, and you are dumbfounded. You are told that it will be 2 hours to get it ready again and now you are angry.
During the earlier months of the COVID pandemic technician hours were bumped up but there are no trained technicians to work the hours specified. How is it possible to train a new hire to work at CVS with such a ludicrous 'feast or famine' model of a work schedule? The simple answer is you don't. The new hire invariably gets stuck on the cash register for hours on end day after day, until he/she finally quits and goes to work for Chick-Fil-A. What is special about Chick-Fil-A you may wonder? You drive up to order your food in either one of two lanes – there are 4 people there (two for each lane) taking your order with an iPad. Pull up another 15 feet and another person takes your payment. Drive up to the window and there are 7 people in there getting your order ready – 'My pleasure.' That's 12 people! How many trained technicians (full-time with more than one year experience) are working with me at 7:30 pm? 99% of the time – ZERO, maybe 1. At some stores the pharmacist is working alone for the final hour. Just what kind of duties are carried on during this final hour? Drop-off prescriptions, production (count, pour, stick, and bag), front register pickup, vaccine administration, DUR, and product verification. Oh, and don't forget there are 2 drive-thru lanes running full-time all day long. Notice anything even remotely similar between CVS and Chick-Fil-A? NO – of course not! Because I'm not selling you a chicken sandwich and lemonade. I am dispensing medication for you and your family members. I sometimes can't resist responding to angry customers when I am making an intervention which could prevent harm, 'This isn't Burger King and you can't have it your way.' CVS has the POTENTIAL to be so much better. It WAS so much better before. Sadly, it's not the will of the corporate management to BE that BETTER company. I wonder if perhaps a current or former executive of Chick-Fil-A might have a better understanding of how to care for people than the current executives of CVS? After all, what greater indicatior could there be for 'The Heart of Health' than highly educated, thoroughly trained, and solidly experienced pharmacist leaders?
What about the long-term technicians who have been at CVS for years? The pay and schedules are demeaning for trained and experienced pharmacy technicians who keep the company afloat day by day. Additionally, who in today's world can accept a job at $16/hour and work 6 hours in one 14-day pay period and then because of 'flex demand' work 80 hours the next? Who can be expected to work as little as 6 hours in one month (the minimum to stay on the payroll) and then respond to the call when needed because of 'flex demand?' Here is a thought – how about hiring a new full-time technician with an agreed upon and fixed number of hours per pay period (60-80 hours) 'in writing' PLUS providing REAL benefits like medical, pharmacy, dental, eye care, etc. that are actually decent? Tom Ryan did it for his employees – why haven't his successors? CVS Health owns Aetna and Caremark that provide medical and pharmacy benefits, but I know full-time pharmacists with one or more family members with chronic health conditions who make out better getting other healthcare coverage for themselves, their spouse, and dependents. That's pathetic!
Earlier in the COVID pandemic CVS hired additional pharmacists and technicians, at least for temporary positions, to help with COVID testing and to give immunizations when the vaccines became available. This increased staffing was very helpful in enabling us to cope with our regular full schedule of responsibilities plus the additional testing, immunizations, and questions. However, once the need for the first two immunizations peaked and began to decline, the added hours of assistance were removed, and the previous hours were cut further. What was the basis for the cut in hours? Well, customers didn't come in to pick up their maintenance medications a year ago when everyone was 'locked down' in one way or another. CVS routinely and blindly adheres to basing hours of staffing upon the amount of business done 1 year ago. But now the immunization demands have increased again because of mandates, recommendations for booster shots, individuals who were not previously vaccinated panicking because of the Delta variant and requesting their first immunization, and the approach of flu season and requests for influenza vaccines. Some stores are providing 30-40 PCR COVID-19 tests a day at the drive-thru window.
These situations have significantly added to and skewed the work flow, but added hours of staffing have not been provided, and hours are even being cut based on the numbers of 1 year ago.
Regrettably, sometimes I wonder if I am losing my own humanity because of the metrics and other demands and continuing stress. I fear I am losing my sense of love for my fellow man. I have turned to viewing those whom I serve as miserable, rude and hateful customers. Grouchy or rude patients I could deal with successfully because viewing the people as 'patients' always elevated my thoughts and actions to the highest level of professionalism, which enabled me to provide outstanding patient care no matter what. Either the patient or caregiver was stressed, worried, saddened, or scared. That motivated me to provide outstanding patient care even when the patient had no idea I was providing it for them. Professionalism enabled me to feel the pain of the person in front of me. Now, however, the extreme negativity at work BECAUSE OF CVS doing nothing and providing nothing is having deleterious effects on my health and attitude. Many interactions with customers become outright arguments within the first 10 seconds. The reasons are all too familiar. Whether it's requesting controlled drugs too soon, the person on the robocall saying 'your medication is ready,' the challenge that a $3 copayment is too high for a $400 inhaler, etc. I have never witnessed so much hostility, disgust, or outright hatred as I have observed over the last 6 months. CVS has sucked the professional life out of me and I can't continue to tolerate these situations. I am willing to take a substantial pay cut and even remortgage our home – anything to be free of this. It's that bad!"
With commendation and appreciation for this CVS pharmacist who has been willing to share his experiences.
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Ivermectin – Clinical Trials are Needed!
The strong differences of opinion regarding the use of ivermectin have intensified and devolved into mandates and threats. Some hospitals/health-systems have mandated that their health professionals must not prescribe, dispense, or use ivermectin for COVID-19. Some medical licensing and specialty boards, at the same time they extol the expertise and credentials of their members, threaten their members who provide "misinformation" regarding COVID-19 vaccines and other COVID-related issues with possible disciplinary actions, including suspension or revocation of their medical license. In a joint statement from three medical specialty boards, it is noted that providing misinformation is unethical, unprofessional, and dangerous. The exclusive focus on misinformation is vague and provides no tolerance for strong but valid differences of opinion among those with similar expertise and credentials. So who will make the determination of what constitutes misinformation? It most certainly will not be the individual physicians and pharmacists who are personally providing the care for their patients and communities. Although most of the threats regarding misinformation pertain primarily to COVID-19 vaccines and have emanated from medical organizations/boards, the number directed against pharmacists is increasing. Providing misinformation can be difficult to define and prove, but prescribing and dispensing ivermectin can be readily documented, and this drug has become a "lightning rod" for mandates and threats.
I had not intended to write more about COVID-19, vaccines, or ivermectin, but a current experience of which I just learned compels me to do so. An individual diagnosed with severe COVID-19 infection was admitted to the ICU of a Philadelphia-area hospital. It is my understanding that remdesivir has been used for treatment and that supportive care and other interventions have been provided. However, his condition has worsened and it is unlikely that he will survive. His wife requested that ivermectin be used for treatment but she was informed that the hospital has established a policy that it won't be used. The patient's wife then obtains ivermectin from another source, brings it to the hospital, and requests that she or a member of the hospital staff be permitted to administer it. Her request is denied, no other treatment/care options are identified, and the patient is considered too ill to survive being transferred to another hospital. How can the refusal to permit the use of ivermectin be justified? Is the refusal to use ivermectin ethical and professional? If the patient dies, will anything change?
Clinical trials should be conducted
There is a desperate need for more and better medications to treat COVID-19 infection. The arguments among those who either support or oppose the use of ivermectin for COVID-19 are even more polarizing and bitter. Clinical trials are needed and I propose the following:
Two clinical trials should be conducted – one to study the use of ivermectin in preventing symptoms and active infection in individuals who have tested positive for COVID-19, and the second to study its use in treating individuals who are experiencing active infections. A group of experienced clinicians and researchers that would include equal numbers of proponents and opponents of using ivermectin, should be convened and supported to design, conduct, monitor, evaluate, and disseminate the results of the studies. A sufficient number of patients should be included in the trials to provide results that are statistically significant and credible.
Who should support/sponsor the clinical trials of ivermectin? Pharmaceutical companies will not do so because ivermectin is off patent and would not provide the revenue to which they feel they are entitled. Healthcare agencies such as FDA, CDC, and NIH should be expected to conduct such trials for the clarification of differing opinions and benefit for the citizens they are expected to serve, but they may be perceived as politically influenced. That brings us to the organizations of health professionals such as AMA, APhA, and ASHP, notwithstanding their joint statement in opposition to ivermectin use, who should be expected to be objective but do not have the resources to fund and conduct such clinical trials. Perhaps the only remaining option is to identify one or more wealthy entrepreneurs or foundations which do not have a vested interest in the results and conclusions of the trials but for altruistic reasons would provide funding. The conclusions of such trials will be of value in either determining benefit of ivermectin and extending its use, or determining it is of no benefit and rejecting its use.
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