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"Do not be overcome by evil, but overcome evil with good." Romans 12:21
Each issue will include an editorial on a topic that is important for the profession of pharmacy, as well as a review of a new drug that includes a comparison of the new drug with previously marketed drugs that are most similar in activity, and a New Drug Comparison Rating (NDCR) for the new drug. Read on for this month's issue.

July 2023 Issue [Download PDF format]
In this issue:
• Can a Large Chain Change Priorities? If I was the CEO of………
EDITORIAL:

Can a Large Chain Change Priorities? If I was the CEO of………

I have often written about the terrible working conditions in many chain stores and in certain other pharmacy workplaces. These conditions increase the risk of errors for patients and moral injury for pharmacists and their colleagues. To be clear, this criticism is directed to the executives/management of these companies who establish the policies and metrics, and not to pharmacists working in these stores. Indeed, many of these pharmacists are heroes based on their perseverance and accomplishments while contending with unrealistic, understaffed, and unsafe working conditions, and keeping patient and employee "casualties" at a minimum.

These chain pharmacies are the largest employers of pharmacists and are the ones that are most familiar to most of the public. I have voiced my opinion that they are destroying the reputation and the future of our profession of pharmacy. Many high-school- and college-age students who work part-time in a chain store will not consider pharmacy as a career choice because of the negativity and stress they observe and hear from pharmacists and other employees. I consider this to be the most important reason for which most colleges of pharmacy are experiencing a large reduction in the number of applicants. Customers who use these pharmacies, often as a requirement or incentive of their employer's prescription benefit plan, are increasingly critical of waiting in long lines in the store or drive-thru, delayed deliveries from the chain's mail-order pharmacy, and prescription mistakes, while concurrently being deluged with store promotions. Serious prescribing and dispensing errors that occur sometimes receive widespread and highly negative publicity, but the vast majority of such errors are unknown to the public, or even to state boards of pharmacy, because the chains compensate the victims or "settle" lawsuits with restrictions that require confidentiality regarding the experiences.

CVS, Rite Aid, and Walgreens are the companies that identify as pharmacies and employ the largest number of pharmacists. Although Walmart, Costco, and some supermarket grocery chains have pharmacies, the pharmacy department only represents a small fraction of the employees, financial operations, and priorities of these large retailers. CVS and Walgreens each have approximately 10,000 stores, and Rite Aid has about 2,500.

Over several decades the number of chain stores significantly increased. CVS, Rite Aid, and Walgreens each opened many new stores, but their growth also resulted from their acquisition of smaller regional chains. Their strategy with respect to independent pharmacies which they regarded as competitors is viewed by many as predatory and even threatening (e.g., "if you don't sell your pharmacy to us, we will open a pharmacy close by and you will probably go out of business"). Many pharmacist-owned independent pharmacies were sold to these and other companies, and a number of other independent pharmacies have closed when the owner decided to retire and was not able to identify a purchaser who wished to continue the facility as a pharmacy. The substantial reduction in the number of independent pharmacies has resulted in many large areas/communities without even one independent pharmacy, and many rural and inner-city communities have only one chain pharmacy.

During the same period of time in which the actions of CVS, Rite Aid, and Walgreens have had a large impact on the sale and closure of independent pharmacies, these three companies have intensely competed with each other, as well as other large retailers with pharmacies. For example, there are many communities in which two, or even three, of them are in close proximity to each other and there is not another pharmacy within many miles in any direction.

Most recently, the combination of the competition among the large retailers with pharmacies, the stranglehold on compensation for the provision of prescriptions and related services by PBMs and health insurance companies, and the COVID-19 pandemic have created a situation in which even the chains have challenges in the financial operations in their prescription departments. If CVS, Rite Aid, or Walgreens ever had an interest in providing professional services/consultation for patients, as well as the welfare of their pharmacists and other employees, management abandoned those interests years ago. Therefore, the financial challenges being experienced now relate to the most basic and fastest components of preparing a prescription (i.e., count, pour, stick, and bag). The consequences are the reduction of the number of hours that many chain stores are open, and closure of some of the stores. As an example, CVS is in the process of closing 900 of its stores over a period of 3 years. Some of the stores that are being closed are in areas in which there are no other pharmacies, but the stores are not considered profitable enough to meet company expectations. This situation has resulted in an increasing number of large "pharmacy deserts," in which there is no pharmacy within many miles. Consumers, society, and our profession of pharmacy are victims.

The management-imposed policies and metrics at the three largest changes do not provide the opportunity, time, or incentive for their pharmacists to speak with customers or monitor their drug therapy. If anything, the incentive is to restrict the time spent communicating with patients to an absolute minimum so that better metrics can be obtained. Any statement from these organizations that they have a commitment to the health of their customers is a charade. For example, the efforts of these chains to increase or eliminate the ratio of technicians to pharmacists are claimed to be for the purpose of freeing up more time for the pharmacists to speak with and counsel patients, and monitor their therapy. However, these claims are false and the efforts to employ more technicians are motivated only by economics and profit. The reality is that these chains are reducing the hours of both pharmacists and technicians. They are hiring "licenses" that can be terminated and replaced at their choosing, rather than recognizing, hiring, and utilizing the expertise, skills, and potential of dedicated professional pharmacists.

Can CVS, Rite Aid, or Walgreens change?

The corporate philosophy and policies of these three chains and their intense competition with each other have resulted in a negative spiral of increasing errors, harm, and moral injury. It has become a destructive race to the bottom for customers and employees, with rewards available only for the executives/management. Some will consider it naïve to even consider it but what if, instead of taking actions that have been so harmful for so many, one of these companies would radically reverse course and commit to provide the best comprehensive professional services for patients, as well as enjoyable and fulfilling positions for employees to the extent that they would be loyal advocates for their company? I find this concept of sufficient interest to consider which of the three largest chains might be the best to consider it.

CVS – With all of its acquisitions CVS is so large, has been so evil for so long, and is viewed by many as inflicting more destruction on the profession of pharmacy than any other organization or situation, that it would seem to be impossible to make major changes. One has to wonder whether the nurses, physicians, home healthcare personnel and others CVS is hiring have any idea of the conditions CVS pharmacists experience and how they view the company. For CVS to reform would be like moving a mountain. God could do it but pharmacy/pharmacists can't move the CVS mountain, and we can't anticipate divine intervention.

Rite Aid – At one time Rite Aid owned about 5,000 stores. It was apparently financially stable and even profitable until the greed and illegal activities of Martin Grass, its then CEO and son of the founder, caused a cascade of financially devastating consequences from which Rite Aid has still not recovered. Martin Grass served a prison term for his illegal activities, but the company and its pharmacists and other employees are continuing victims of his personal greed. Since the misadventures of Martin Grass, there has been a revolving door in the Rite Aid executive offices (when they still had offices before working remotely), with none of the numerous subsequent CEOs being able to turn the company around. On several occasions Rite Aid has tried to sell itself to larger companies. These efforts have not been successful although it did sell about half of its stores to Walgreens. Rite Aid has about 2,500 stores now, and continues to be plagued with quarterly losses and leadership changes. It must give priority to its own survival and is very unlikely to consider progressive change as the strategy to do so, although I would encourage and support that initiative if it chose to do so.

Walgreens – Started in 1901 by Charles R. Walgreen, Sr., Walgreens has by far the longest history of the three largest chains. For much of its history (but not currently), pharmacists served in executive leadership positions. Of the three largest chains, I consider Walgreens to be the best candidate to "reform." I fully expect that I will hear from many readers, mostly current or former Walgreens employees, that the corporate philosophies and metrics, as well as the workplace conditions, are as bad as those at CVS or Rite Aid, and that I am crazy (or worse) for making such a suggestion. However, to not propose that one of these three corporations could change for the better would be abandoning hope and giving up. The following are among the reasons for my suggestion:
  1. Walgreens has the size and resources to make a difference.

  2. Walgreens has valued and maintained the corporate name of its pharmacist founder, thereby demonstrating a continuing commitment to the family, history, legacy, and pharmacy identity of its organization.

  3. At various times in its history. Walgreens has attempted to implement patient- and pharmacist-centric initiatives that, unfortunately, have been of brief duration and are not evident at the present time.

  4. Although I do not have supportive data, it is my impression that the stability of employment of pharmacists in middle-management positions (e.g., pharmacist district leaders/managers) is better than that at CVS or Rite Aid.

  5. Walgreens, as well as CVS and Rite Aid, have been "risk-takers" in seeking competitive advantages although some of these initiatives have had disastrous results.
I recognize that major changes in priorities for a large organization involves risk and a substantial investment of resources for which there will not be a short-term financial benefit. However, professional benefits can be achieved quickly and eventually will be accompanied by financial benefit for the organization. This is consistent with the concept of investment, and I view the opportunity to be one that involves less risk than some of the ventures that Walgreens has unsuccessfully pursued (e.g., losing millions of dollars by investing/collaborating with Theranos).

If I was the CEO of Walgreens, I would take the following steps to initiate changes and quickly build support and momentum:
  1. Convene a group of employees and external advisors who have expertise and experience that I do not have (e.g., business expertise, experience with innovative professional pharmacy practice models) to identify the components of a plan for progressive professional change.

  2. In consultation with colleagues, identify the components of the plan and preliminary strategies for implementation. Announce the plans to employees and shareholders, and publicize them to pharmacy media, colleges, and organizations.

  3. Discontinue the sale of tobacco products and other product lines that can cause harm and/or are otherwise inconsistent with a commitment to improving the health of customers and the public. This action will be enthusiastically welcomed by pharmacists, other advocates for public health, and communities. In collaboration with local fire departments and with arrangements for the presence of civic leaders and media coverage, arrange a supervised fire to burn existing inventories of tobacco products in front of the store. The media coverage will provide the opportunity to announce other steps to be implemented as part of the more comprehensive plans, and will result in extensive and very favorable publicity and relationships with the community.

  4. Establish and publicize "customer service and safety" and a "fulfilling professional workplace for employees" among the highest-priority commitments of the company.

  5. Renovate prescription departments and a waiting area where needed to provide a professional environment that is consistent with the high quality services that customers should expect from the pharmacy team

  6. In consultation with store-level pharmacists and technicians, identify the staffing and scheduling arrangements that will assure communication/counseling for all customers with prescriptions and other health needs, appropriate medication use review, communication with prescribers, and the attainment of optimal drug therapy outcomes. The synchronization of providing refills for maintenance medications and the scheduling of appointments for return visits with the pharmacist are examples of steps that can be taken that will be well received by patients and which they will share with family members and friends. Currently employed pharmacists who do not have experience or a comfort level in assuming these responsibilities should be provided the opportunity to participate in programs that will prepare them to do so.

    I recognize that this action will require the employment of additional pharmacists and technicians, and a substantial increase in salary budgets. However, this initial investment should result in longer-term professional and financial benefits. The resultant professional and fulfilling workplace conditions will enhance employee wellbeing and will be of great value in recruiting and retaining pharmacists and other staff who will be loyal employees. Walgreens will come to be recognized as the best option for pharmacists who are pursuing employment in a chain pharmacy, and there will be a large reduction in employee turnover and the associated costs of training new employees.

  7. Provide a compensation package for pharmacists that includes shares of Walgreens' stock that will enhance the awareness of the relationship between the pharmacist's performance and the company's performance. Pharmacists and other employees should be encouraged to provide suggestions/recommendations that will improve/expand company programs and services.

  8. Establish a recognition system that includes documentation of interventions by pharmacists that prevent prescribing and other errors, as well as misunderstandings of patients with respect to the use of their medications. These experiences (with appropriate redactions for confidentiality) will also be of educational value for pharmacy teams throughout the company.

  9. Encourage and recognize the participation of employees in community and civic programs, and the involvement of pharmacists in professional organizations. As part of the company's benefit package for pharmacists, include membership in the American Pharmacists Association and the state Pharmacists Association.

  10. Explore with the National Community Pharmacists Association the potential for establishing collaborative programs and services involving independent pharmacies and Walgreens stores in geographic areas in which both are located.
Ten recommendations are enough to get started but readers are encouraged to provide additional suggestions.

I am sometimes asked whether I send my commentaries to the executives of the pharmacy companies/organizations about which I write. Only a relatively small number of them are subscribers to The Pharmacist Activist, but many of their employees/members are. I am confident that my commentaries are brought to the attention of the executives, either directly or anonymously. I have never met Rosalind Brewer, the CEO of Walgreens Boots Alliance, and do not expect that I would be able to personally meet/speak with her. However, I do anticipate that this commentary will reach her.

While Walgreens is ignoring, considering, or rejecting these recommendations, it is possible that some executives of Rite Aid may have some interest. Rite Aid's organizational and financial challenges are so formidable that it would seemingly have little to lose by radically reversing course and implementing many of the recommendations provided here. And if both Walgreens and Rite Aid were to do that, it would be all the better and for the great benefit of the companies, patients, society, and the profession of pharmacy.

I would be remiss if I concluded this editorial without recognizing that many independent pharmacists who are reading this are thinking that they are currently doing most of the things I have recommended and have been doing so for years. They deserve our commendation and appreciation for providing the "life preserver" for our profession, but they are in deep water and deserve and require the support and "rescue" from our entire profession.

Daniel A. Hussar
DanH@pharmacistactivist.com

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