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"but those who hope in the Lord will renew their strength. They will soar on wings like eagles, they will run and not grow weary, they will walk and not be faint." Isaiah 40:31
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.

October 21, 2023 Issue [Download PDF format]
In this issue:
• If Independent Pharmacies Do Not Survive, Our Profession Won't Either! But Most "Leaders" Don't or Refuse to Recognize the Relationship!
• "After working many years in independent pharmacies, I now work in a mail-order pharmacy."
EDITORIAL:

If Independent Pharmacies Do Not Survive, Our Profession Won't Either! But Most "Leaders" Don't or Refuse to Recognize the Relationship!

On numerous occasions I have voiced my belief that the ability of independent pharmacies to not only survive but thrive is inextricably entwined with the ability of the profession of pharmacy to survive and thrive. As the threats to the survival of independent pharmacies continue to increase, and the number of independent pharmacies continues to decrease, I am increasingly convinced that my "belief" will become a certainty unless urgent actions are taken.

I am not a leader of our profession, nor do I aspire to be. However, I do have longevity and experiences within pharmacy that position me well to have reasoned perspectives and opinions that younger pharmacists have not yet had the experience to acquire. I do not claim to have the wisdom or vision to identify the strategies and actions that will best assure future successes for our profession. Priority must be given to increasing communication and collaboration of pharmacists and our organizations for the purpose of identifying ideas, strategies, and actions that will best position our profession to effectively respond to the challenges and plan for the future. That is occurring to only a limited extent now, notwithstanding the numerous diverse but changing coalitions, consensus conferences, and joint statements that purport to represent the interests of pharmacists and the patients we serve.

With the disclaimer that I do not have a crystal ball and can be wrong, I know that many of the elected and other leaders of our profession are aware of, and may even read the opinions and recommendations I include in The Pharmacist Activist. However, with the notable exception of one pharmacy leader who speaks with me on a regularly scheduled basis to "brainstorm," most others ignore or decline to identify with the ideas or the individual who might be considered radical, provocative, nostalgic, out-of-touch, or all of the above. But if there is one thing I have acquired in my long experience, it is "thick skin" as a result of so many of my opinions and ideas being ignored, rejected, and/or ridiculed. I am motivated to continue my advocacy for pharmacy in general, and independent pharmacists in particular, because of the supportive comments I receive from many pharmacists, as well as the differing opinions from which I continue to learn.

If independent pharmacies disappear - ABANDONMENT!

The vast majority of the American public obtains their medications from a community or mail-order pharmacy. The public, as well as the profession of pharmacy, are already experiencing the consequences of the corporate dominance of this marketplace. Huge health insurance companies, their pharmacy benefit managers (PBMs), and the brokers that work with them wield almost complete control over the economics of providing medications and the payments to pharmacies. These entities extract huge amounts of money from the healthcare system but contribute absolutely nothing to the quality and scope of services and care for individual patients. Many independent pharmacies have closed and, if they disappear, who will assume their roles of personally communicating with and counseling patients, responding to their questions, and assessing their use and outcomes of medications?

Most chain pharmacists would like to fulfill those roles but the largest corporate owners of chain (e.g., CVS, Walgreens) and "big-box" (e.g., Walmart) pharmacies are obsessed with profits and share values and operate their pharmacies with minimum and insufficient staffing. Most chain pharmacists do not have the time, encouragement, or incentives to assume these responsibilities. Their chaotic and stressful workplace conditions result in moral injury for pharmacists and other employees, little or no personal communication with and counseling of patients, and an increased risk of errors and harm. The frustration and anger of chain pharmacists and technicians has been evident for years in social media forums and, most recently, by walkouts of CVS and Walgreens employees.

"Pill mill" mail-order pharmacies dispense hundreds of thousands of prescriptions prepared by pharmacists and other employees to patients who are invisible and unknown to them, and involve no face-to-face or other personal communication. Beyond the distribution of medications, most mail-order pharmacists can't provide any personalized care and services for customers.

Independent owner and staff pharmacists are the last line of personal representation of the profession of pharmacy with the vast majority of the public (for the purpose of discussion, I suggest what is probably a low estimate of 90% of the U. S. population). However, the substantial decline in the number of independent pharmacies has resulted in the loss of professional and personalized counseling and services for a large segment of the population. Some independent pharmacy owners have responded by reducing staffing and services, but this is a self-defeating strategy that erodes their greatest strength of knowing and serving their patients and communities.

One would think that the situations described above would be of great concern for the entire profession of pharmacy that has enjoyed an excellent reputation and opportunities over many years that is primarily attributable to the positive relationships and services that the public has experienced with independent pharmacists. However, with the exception of the National Community Pharmacists Association (NCPA) and a limited number of other organizations and individuals, independent pharmacists have been essentially abandoned by most of the rest of the profession. The even larger question is:

IS THE PROFESSION OF PHARMACY ABANDONING 90% OF THE U.S. POPULATION TO THE PROFIT OF CHAIN AND MAIL-ORDER PHARMACIES?

Those of us who practice in areas of pharmacy other than community pharmacy may have very important and fulfilling professional responsibilities. However, regardless of whether we are employed in a health-system pharmacy, college of pharmacy, pharmaceutical company, or another area, we and our responsibilities are essentially invisible and unknown to the vast majority of the public.

If independent pharmacies disappear, it will be the chain, big-box, and mail-order pharmacies that will be the distributors of medications, as well as the identity/image of the profession of pharmacy for the public. With few exceptions, these employed pharmacists will not have the opportunity and time to provide assessment, counseling, monitoring, and other services that will assure optimal, effective, and safe therapeutic outcomes. These pharmacies employ many dedicated pharmacists, but the executives/management impose minimum staffing and metrics that result in chaotic, stressful workplaces that frustrate and anger customers and employees alike. Employees of mail-order pharmacies may experience less stress, but personalized communication and services for customers are essentially nonexistent. If independent pharmacies disappear, it can't be expected that the corporate ownership/executives of the remaining retail pharmacy corporations will suddenly become ethical and professional, and provide services for patients. They won't, and errors and harm for customers will occur more frequently than they do now.

By our failure to support and strengthen independent retail pharmacy, many within our profession are abandoning those who have historically been the face and soul of our profession for the public. These identities are rapidly being assumed by the corporate chain and mail-order pharmacies whose pharmacists are usually inaccessible and/or invisible. How can our profession continue to claim that we are advocates for the highest standards of pharmacy practice, communication with and services for patients, and pharmacists practicing "at the top of their licenses," when most of those in retail pharmacy do not have the opportunity to practice in this manner and have little hope of being able to do so in the future? The public does not like and increasingly fears what they are experiencing, and claims of our profession to the contrary are a charade.

The scenarios discussed above have already claimed thousands of pharmacists as victims. Many independent pharmacists were the first victims and they are being followed by many chain pharmacists who are trapped in intolerable workplaces or are losing their jobs as CVS and Walgreens are each closing hundreds of stores and Rite Aid declares bankruptcy. Employment in the assembly lines of mail-order pharmacies has to be the least fulfilling position for those who may have previously aspired to provide personal advice and services for patients, but this disadvantage is offset for some by better work schedules and their escape from stressful retail workplaces and customers who are angry because of delays and the complexities, inconveniences, and costs of their prescription plans.

Many county/local and state associations of pharmacists were the next victims. Historically, it has been independent pharmacy owners who have provided the membership and strength of these organizations. However, as the number of independent pharmacies/pharmacists has declined, many of these associations have become inactive or have been dissolved. Colleges of pharmacy and their faculties will be the next victims as the number of applicants and enrollments have sharply declined in recent years. This is much more than a periodic downturn in a supply-and-demand cycle, but rather, in my opinion, is a consequence of the large chain pharmacies destroying the applicant pool. As the employers of the largest number of pharmacists, technicians, and part-time high-school students and other young people, many of those in the latter group who are in the process of making career and college decisions are repulsed from, rather than attracted to a career in pharmacy because of the stress and negativity they observe and experience in their stores. Some colleges of pharmacy will close, and it continues to surprise me that many in academic leadership positions fail to recognize the correlation between the abysmal working conditions in many chain stores and the substantial reduction in the number of applicants to colleges of pharmacy. I and many others consider CVS and its component companies (e.g., Caremark, Aetna) as having the greatest destructive influence on the profession of pharmacy. However, it is my perception that many deans and other leaders of the profession give priority to obtaining scholarships, grants, and other funding from CVS, but refuse to voice concerns about levels of pharmacist and technician staffing and working conditions.

Even many current pharmacy students have never been in an independent community pharmacy. If I was a dean of a college of pharmacy, I would work with the faculty to have students participate in the required advanced pharmacy practice experience (APPE) in community pharmacy in an independent pharmacy. Colleges of pharmacy presently have other additional ways in which they can support and strengthen independent pharmacies. However, most have other priorities and, as with independent pharmacies, they will soon experience a decline in their numbers!

The NCPA meeting

In "retirement" I attend fewer pharmacy meetings that I once did. One of the meetings that I continue to attend is the NCPA annual meeting. Even with the challenges they are facing, the independent pharmacists demonstrate professionalism and determination that I find encouraging and inspiring. If they can demonstrate resilience and perseverance, the least I can do is support them.

The meeting this year was just held October 14-17. Before considering the "positives" of the meeting, I will share several concerns:

I am not aware of specific registration numbers, but it is my perception that the number of independent pharmacists in attendance continues to decline. This is not surprising in consideration of the threats to the financial survival and declining numbers of independent pharmacies.

There were very few deans and faculty of colleges of pharmacy in attendance. Much more encouraging was the number of pharmacy students in attendance. Even with much more limited experience, they recognize the potential for professionally fulfilling opportunities that have escaped the awareness of many of their faculty.

The number of organizations/groups with which independent pharmacists are affiliated (e.g., large wholesalers, wholesaler collaboratives, buying groups, "specialty" groups) fragments representation and detracts from the potential for greater strength of a more unified and effective organizational structure. (I have often made similar observations regarding what I consider to be the weaknesses of the current organizational structure "representing" the entire profession of pharmacy at the national and regional levels).

However, the positives of the meeting transcend the concerns and include the following:
  1. The singing of the national anthem and the invocation at the opening general session represented a continuing commitment to faith, freedom, and patriotism for those of us who consider them to be foundational values in fulfilling our personal and professional responsibilities.

  2. The dedication, perseverance, and even optimism and enthusiasm of the pharmacists in attendance, even in the context of threatening challenges. The "spirit" of professionalism and independence is as strong as or stronger than I have observed in any other group or organization of pharmacists.

  3. The legal actions that have been initiated offer the hope of recovery of direct and indirect remuneration (DIR) fees and equitable compensation for pharmacies. It had been recently announced that Matt Osterhaus of Iowa is the lead pharmacist in a class-action lawsuit against CVS Health, CVS Caremark, and Aetna. At the meeting it was announced that NCPA was "creating a limited liability company called TRUST LLC, which will investigate and, when appropriate, litigate or arbitrate on behalf of community pharmacists to recover coerced price concessions." (i.e., DIR fees) which have been assessed by PBMs and insurance plans and appear to be in violation of federal antitrust law and state contract laws. The NCPA is working with three law firms that are participating on a contingency basis, each of which had representatives speaking at the general session and in small group discussions with pharmacists. In the group discussion that I attended, I voiced my opinion that these are the boldest and most exciting initiatives I have seen taken to protect and expand the future for our profession. Additional information about TRUST can be accessed at www.fightPBMs.com. Solidarity, strength, and effectiveness in these efforts can best be achieved by every independent pharmacist owner being a member of NCPA, and making the commitment to be a participant in these actions to recover unfairly extracted fees and compensation, and to protect against future inequitable compensation. Successes will not come easily or quickly, but our profession must support these actions.

  4. Dr. Marty Makary is a surgeon and Professor of Health Policy at Johns Hopkins School of Medicine/Bloomberg School of Public Health. During the COVID-19 pandemic I saw him interviewed on numerous occasions. I was very impressed by his expertise and the clarity in which he shared his knowledge and reasoned perspectives, and his boldness in challenging certain mandates and directives of government officials and "experts" from national health agencies. He was the keynote speaker at the second general session of the NCPA meeting and it was quickly apparent that he sees and understands "the big picture" of health care and its successes and failures. His excellent analyses spanning many areas of health care were concerning but also enlightening and motivating for action by health professionals. I obtained his book, "The Price We Pay: What Broke American Health Care and How To Fix It," which reviewers have assessed as "A must-read for every American" and "A call to action for medical professionals." I urge you to read it and pursue the actions you are in a position to take.
There is no status quo in health care. If we don't take urgent action, the situation will only worsen.


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 EDITORIAL:

"After working many years in independent pharmacies, I now work in a mail-order pharmacy."

Editor's note: I provide the following exchange of messages with a pharmacist friend for the purposes of increasing awareness of the challenges faced by independent pharmacists and cautioning them to not take actions that could compromise their greatest strengths. Soon after reading my August issue of The Pharmacist Activist, a pharmacist whom I know well and hold in high regard sent me the message that I have provided below, with the above title included in the Subject line. The message provides very important perspectives regarding the challenges and decisions faced by individual pharmacists, pharmacists who own independent pharmacies, and our profession of pharmacy. I would very much like to identify and give credit to this pharmacist and the independent pharmacies/pharmacists that provided many years of employment. I would also like to give credit to the specific mail-order pharmacy for providing a satisfying employment opportunity for this pharmacist. Although I would anticipate that the current employer would view the comments as positive and be pleased, I can't rule out the possibility that it would interpret them differently. Accordingly, I am not identifying the pharmacist or the pharmacies.


September 5, 2023

Hello Dan:

This is an email I've intended to write for some time now but one I struggle with immensely. My struggle is that I don't want to disappoint you! I've actually wanted to reach out to you over the past few years as I have been struggling. I know that you know this and have heard it over and over again, but I want to share my story with you. Even in the awesome environment of independent pharmacy, retail is tough! Nowhere near the struggles of chain pharmacists, but still very challenging. It came to a point where I was becoming a person I didn't like and was too burned out, so I made the switch to a mail-order pharmacy.

I went into pharmacy because I wanted to help people and still do! That being said, some people have become so difficult to deal with. Especially after the pandemic, it is so much worse. Then add on top of that, to process a prescription, I need to consider the type of insurance a patient has. Will we lose money if we process this claim? Then the drug-drug interactions are endless and the "pop-up fatigue" is real. And then we have our immunizations. I became certified and actually ended up loving it. But as time went on, I began to question the CDC guidelines….do people really need 5 or 6 COVID vaccinations? Of course, many of the others – influenza, pneumonia, shingles – are super important and a great convenience being offered at the local pharmacy. But overall I became no longer comfortable trusting the authorities I always held in such high regard. Our profession has changed from taking care of people to having to worry about the bottom line. Would the pharmacist owner be upset because I dispensed a prescription for which we lost money, or did I ask enough people if they would like a Shingrix shot?

So it was a 3-year process for me to make the change and a very bittersweet decision. I was against mail-order my entire career as it goes against everything I believe pharmacy is about. However, as a BS degree graduate, my options are very limited. I have learned that most places, other than retail, won't even consider those of us who don't have the PharmD degree – my years of experience mean nothing. That was a very difficult realization for me to come to terms with. But over time, I realized that I am a dispensing pharmacist and I embrace that now. So that's what led me to mail-order pharmacy. I work for (redacted) and, honestly, I once again love my job! I certainly miss many of my patients from (redacted) and coworkers but, for my own sanity, I am very happy with my decision. The people where I now work are great, and their biggest concern is the quality of the product and not the amount I can check. There are rates I need to meet, but they are very achievable and they keep saying "it's much more important that it is correct." The rates only exist because we are a production company and need to show we are getting things done. So that is a little bit about my story. I am so sorry if it disappoints you to hear I left the independent pharmacy. I do still struggle with the loss of that identity I valued for so long. I was so proud to be that neighborhood pharmacist. I'm so sad as to what our profession has become.

Thank you for reading my rambling story! I hope this finds you well. I enjoy your monthly newsletter and so admire you for all you continue to do for our profession.

With regards,

Xxxxxx Xxxxxxxx


My response on September 6, 2023

Hello Xxxxxx:

Thank you for your message and sharing your experiences and insights. Please be assured that I am not disappointed in you! Indeed, I commend you for your dedicated service to (redacted) and the many patients you served. You and your colleagues there have been wonderful advocates over many years for your patients, your community, and our profession of pharmacy. My only regret is that, because independent pharmacies receive such poor reimbursent and are victims of DIR fees, some find it necessary to focus more on financially surviving, which ultimately harms the independent pharmacy experience for both customers and employees. But I do not fault the pharmacist owners of these pharmacies, because over a period of many years, the owners/pharmacists and employee pharmacists have provided such professional and enjoyable experiences that have been the primary reason for which many young people chose pharmacy as their career, and some became highly accomplished leaders of our profession. Even in these much more difficult times, I highly commend them for remaining in operation and serving their communities.

With regard to your personal decision, you are in the best position to identify the employment that is best for your life situation at this time, and for your personal physical and mental wellbeing. I would never fault you for choosing the situation/company in which you are employed because I have complete confidence in your judgment and decision. Although I am a very strong advocate for independent pharmacy, you have lived that experience and provided benefit for thousands of patients for many years.

I fault myself and many others in the profession for not anticipating the challenges our profession now faces, and for not taking actions that might have prevented or minimized them. We have not done nearly enough to protect and advance our profession for those who follow us. It is this recognition that motivates me now "in retirement" to say and do as much as I can to be an advocate for independent pharmacists, particularly friends such as yourself.

I would enjoy personally speaking with you. Would you please provide me with your phone number and a few times when it would be convenient for you to speak by phone?

With friendship and appreciation –

Dan


The pharmacist's response later on September 6, 2023

Dan:

Thank you so much for your kind words. They mean much more to me than you can ever know as it's been weighing on me for some time. I would value the opportunity to speak with you. My cell phone number is (redacted), and I am usually available on (redacted). Looking forward to our conversation.

(Because I stay up late and am in the eastern time zone, we were able to speak that same evening [September 6] for more than an hour. I am inspired by the fine personal qualities and professionalism of this pharmacist. But are the leaders of our profession recognizing the experiences of this pharmacist and many others, and taking necessary actions?)

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