EDITORIAL:
The Walgreens Disaster
Ihave often been critical of the executives/management of Walgreens, but have great concerns about its downfall and recent sale to the private equity firm, Sycamore Partners, for $10 billion. Almost immediately following the announcement of its sale, I received a message from my friend Dan Hoffman, President of Pharmacy Research Business Associates (PRBA). Dan responds to most issues of The Pharmacist Activist with usually constructive criticism which I value. He concurs with most of the concerns I voice, but does not feel I am provocative enough or sufficiently critical of pharmacy leaders and other decision-makers (and I agree). He also urges me to specifically identify strategies and solutions for my concerns, to which I respond that I can make recommendations but do not have the expertise and/or position of influence to identify solutions.
In his message he asked me several questions:
"Do you see Sycamore-owned Walgreens as acting with more or less professional pharmacy integrity?
How about their treatment of pharmacist employees?"
He then proceeded to provide his predictions:
"Given that the acquisitions of other healthcare entities (physician practices, hospitals, nursing homes) by private equity firms result in higher costs, reduced staffing, more medical errors, and less direct contact with patients/customers/clients, my guess is that Walgreens will reach new lows in pharmacy performance and start a more rapid race to the bottom among the chains.
That truly is a threat to pharmacy and its role as a public-facing profession. It's not useful to just bemoan this…, nor is it a help to discuss it in the manner of an academic committee chairman or dean by issuing a laundry list of nonspecific approaches that lack definitive tactics."
I fully agree with Dan Hoffman's opinions, both with respect to the Walgreens organization and its pharmacists and other employees, as well as the threat for the entire profession of pharmacy.
The downward spiral
As recently as 2015, Walgreens had an approximate worth of $100 billion. How could a company that was founded in 1901 and thrived and grown to approximately 10,000 stores, collapse so precipitously? Matt Stoller is a strong critic of monopolies and author of "BIG." His March 14 commentary is titled, "The Real Reason Walgreens Collapsed," and provides an excellent analysis of the challenges Walgreens faced that include some poor and costly management decisions. However, his conclusion is that the "real reason" for its collapse is that it "is being squeezed to death by monopolistic pharmacy benefit managers." Additional pertinent observations from his commentary include:
"But the real reason Walgreens, and the pharmacy business in general, is dying, is because of a failure to enforce antitrust laws against unfair business methods and illegal mergers….I don't think people appreciate the full scope of what happened to Walgreens, and to the full pharmacy business in general. This is not a case of bad management, it's a case of desperate management."
"Here's what happened to Walgreens when it got into a fight with Express Scripts in 2012, just after the Medco-Express Scripts merger….Walgreens eventually came back with its tail between its legs and signed a deal with Express Scripts. At that moment, it became clear that PBMs had all the power, and drug stores had none."
"There were many other mergers…,notably CVS Caremark buying Aetna in 2018. Yes, CVS, a major Walgreens competitor, is setting its revenue, which is insane. (That's why CVS's drug stores entered a host of markets while its pharmacy rivals flailed)."
Neither Dan Hoffman nor Matt Stoller is a pharmacist, but they have extensive expertise about the healthcare system and the economic forces and organizations that threaten it. They have a better understanding and greater concern regarding the threatening challenges for the entire profession of pharmacy than many pharmacists do.
Sycamore Partners
Matt Stoller describes Sycamore Partners as a private equity giant "which specializes in squeezing blood out of failing retailers…. (Walgreens) ‘going private,' particularly to a fund like Sycamore, is an admission of failure."
Sycamore bought Walgreens for $10 billion and has to be anticipating that it will be a profitable investment. It presumably understands the economic challenges for community pharmacies, but it can't be expected that it understands and has a commitment to support and strengthen the professional responsibilities and roles of pharmacists. Rather, its anticipated priority will be to slash costs, close more stores, and reduce pharmacist and technician staffing even more.
Actions
- NCPA and APhA should meet with Sycamore officials to discuss their strategies and plans to the extent to which they are willing to disclose them. NCPA should explore the potential for patient- and pharmacist-centered synergies that might be accomplished through a collaborative working relationship.
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Walgreens' pharmacists should establish a communications network to include as many of the company's pharmacists as possible.
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Walgreens' pharmacists, if they are not doing so already, should actively explore other pharmacy employment opportunities.
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Walgreens' pharmacists who are interested and in a position to do so should explore purchasing the pharmacy in which they work from Sycamore.
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Walgreens' pharmacists should identify and propose strategies to Sycamore that will assure adequate staffing, increase pharmacist–patient communication, expand the professional services of the pharmacists, and enhance the effectiveness and safety of drug therapy for patients. Discontinuation of the sale of merchandise that detracts from a professional environment should be proposed, and recommendations initiated for the utilization of the vacated space for health-related services and products.
Although the circumstances were different, pharmacist Amina Abubakar bought a Rite Aid store in Charlotte that had closed. Extensive renovations were done and the very impressive professional environment emphasizes the roles and services of the pharmacists in providing patient care. Separate areas/offices are allocated for extended pharmacist services (e.g., medical equipment, compounding, immunizations, pharmacogenetics) and other health-related services and products. What she and her colleagues have accomplished is inspiring! If possible, I urge you to visit Avant Pharmacy and Wellness Center or to, at least access its website (avantpharmacy.com).
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EDITORIAL:
The JCPP in Dream World
Pre-assessment
- What is JCPP?
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Who are the members of JCPP?
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What are the JCPP's most important accomplishments?
I begin this commentary with a pre-assessment because when I asked a very knowledgeable and involved pharmacist what he thought about the JCPP's recent statement and request, his immediate response was, "What is the JCPP?" My sense is that this is the way that a large majority of pharmacists would respond.
Answers
- The JCPP is the Joint Commission of Pharmacy Practitioners. It was established in 1977, with a mission to serve as a convening organization to address topics impacting the profession of pharmacy.
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Thirteen national pharmacy organizations comprise the membership of JCPP, and the CEOs of these organizations are identified on the JCPP's website.
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Identifying the JCPP's most important accomplishments over a period of almost 50 years is more of a challenge. Perhaps the most important accomplishment is that it provides a forum for the leaders of the organizations to periodically speak/meet with each other (in-person?, remotely?, through a designated representative?), when they might not otherwise do so. A recent JCPP news release notes that the organizations work "collaboratively to support achievement of the JCPP Vision for Pharmacists' Practice.
The JCPP Vision
In 2004, the leadership of the JCPP's member organizations developed the statement, "Pharmacy's Vision for 2015," (noted below) that was endorsed the following year by all of the participating national organizations.
"Pharmacists will be the health care professionals responsible for providing patient care that assures optimal medication therapy outcomes."
The vision statement and the supporting discussion were both bold and progressive, and provided a platform from which the JCPP and its member organizations could have developed and implemented strategies, plans, and support that would result in the vision becoming reality. A period of ten years was considered sufficient to achieve this goal.
The March 2015 issue of The Pharmacist Activist included my editorial with the title on a tombstone:
PHARMACY'S VISION FOR 2015
2004 – 2014
REST IN PEACE
What happened? In a word, the JCPP and its member organizations FAILED! Once the excellent vision statement was developed, the leaders again immersed themselves in the priorities and business of their individual organizations, while essentially ignoring the vision that was so important for the entire profession of pharmacy. Over the following 10 years, there was so little mention or awareness of the Vision that, when 2015 arrived, the JCPP and its member organizations must have assumed that most pharmacists who knew about it would have forgotten it, and that "breaking the silence" regarding it would result in criticism. However, when a few pharmacists raised questions, we were quickly informed that the Vision for 2015 had not been abandoned but had been revised to place greater emphasis on patient benefits. Who knew?
I checked the JCPP website and located the following statement that was apparently adopted in 2014 with no publicity:
"Patients achieve optimal health and medication outcomes with pharmacists as essential and accountable providers within patient-centered, team-based healthcare."
This is another admirable statement, but there are several changes that are noteworthy. It is more of a declaration as to the role of pharmacists as a member of a team that could provide optimal outcomes for patients at the time (2014) the statement was adopted, rather than a goal-oriented vision that will challenge the profession and individual pharmacists to attain the vision. Unlike "Pharmacy's Vision for 2015," there is no date identified at which the statement should be considered accomplished or reviewed again.
In my opinion, the most important revision is the inclusion of the word "accountable," a change with which I fully concur. However, it is the pharmacist providers who are identified as those to be considered accountable. It is NOT the JCPP or the leaders of its member organizations who are not providers themselves but who compose the visions and other dreams that, with few exceptions, are essentially impossible to attain by their "accountable" provider members without strong support of the entire profession. This support has not been provided and the JCPP and the leaders of its member organizations have not been accountable for their failures such as Pharmacy's Vision for 2015 and related statements.
Ten more years
It is now 2025 and twenty years have elapsed since the development of the ill-fated Pharmacy's Vision for 2015. Last month I became aware that the JCPP was working on another initiative and had identified a "public comment period" during which it was requesting feedback from pharmacists. I accessed the JCPP website and first observed that the "Vision" had been revised again to the following:
"Pharmacists, as part of the healthcare team, are responsible for achieving optimal health, wellness, and medication outcomes for all people."
This second revision (and there may be others of which I am not aware) is more similar to the initial Pharmacy's Vision for 2015 than it is to the first revision (2014). However, there are important changes. Unlike the first two vision statements, the word "patient" does not appear in the current version, and has been replaced by "all people." Unlike the first revision, the word "accountable" has been deleted. Although there have been numerous changes in the leadership of the JCPP and its member organizations over the last 20 years, it becomes more difficult to have confidence in the organizations and their leaders who compose statements and make decisions that are of utmost importance for the profession of pharmacy in an essentially unannounced and unknown process for which there is no accountability.
The latest JCPP initiative
The Pharmacists' Patient Care Process (PPCP) has been described as "the foundation for the essential care that pharmacists provide to patients on a daily basis." Developed in 2014, the JCPP is revising this document "to reflect contemporary pharmacy practice today and into the future." Pharmacists were informed that our opinions are important, and were asked to review the draft revised PPCP and respond to a survey. It is noted that "the estimated time to review the draft revised PPCP is 10 minutes." If it takes 10 minutes for a pharmacist to review the statement, it would be anticipated that it would take longer than 10 minutes to provide the services/care identified for each patient. This is described as "the essential care that pharmacists provide to patients on a daily basis," and reflect "contemporary pharmacy practice today and into the future." Mail-order pharmacies and large chain pharmacies dispense more prescriptions than all other pharmacy practice sites combined. How many minutes, or even seconds, do you think a mail-order pharmacist commits to fulfill the PPCP provisions for an individual patient? My response is "zero!" How many minutes or seconds do you think a CVS pharmacist commits, on average, to fulfill the PPCP provisions for an individual patient?
The responsibilities and provisions of the PPCP are laudable, and nothing would please me more than to acclaim them as the care that pharmacists are providing patients on a daily basis. However, the vast majority of pharmacists do not practice in this manner and, if the JCPP members think they do, they are living in a dream world!
Some readers are no doubt wondering how they missed the request to review and comment on such an important document. I encourage you to access and review it, but it is too late for you to respond as the public comment period closed on Friday, February 28 at 5 pm PT. To my knowledge, the document and opportunity for comment was announced in late January, and most pharmacists are still not even aware of it. If my understanding is correct, this process is a sham for the JCPP to claim that an opportunity was provided for pharmacists to comment. My sense is that the draft revised PPCP was essentially considered finalized at the time it was made available to the profession, and that very few comments were anticipated. I urge the JCPP to disclose how many responses were received in the public comment period and the number of these comments that resulted in subsequent revisions in the PPCP.
It is noteworthy and insulting that for more than two decades the JCPP has failed to attain the Vision for 2015, 2025, or beyond, but it requests pharmacists to review and comment within approximately one month from the time the PPCP apparently was made available on a document identified as the "foundation for the essential care that pharmacists provide to patients on a daily basis."
The most important concern, however, that emerges from the analysis of these experiences is that it is the elected and appointed LEADERS of our profession who have prepared the visions and patient care responsibilities through processes that have not been transparent and for which there is no accountability.
What can be learned?
The development in 2004 of "Pharmacy's Vision for 2015," provided a concise, forward-looking, and credible statement that appeared achievable over a period of 10 years. When it was endorsed in 2005 by all of the major national pharmacy practitioner organizations, it offered hope to practicing pharmacists that our profession was committed to expand the professional roles of pharmacists in a manner that would enable pharmacists to more fully utilize their knowledge and skills in achieving optimal drug therapy outcomes for patients. The Vision made no attempt to describe the contemporary daily responsibilities that pharmacists were providing in 2004. It established a goal! The development of the Vision occurred only because the leaders of the largest national pharmacy organizations convened and worked together to provide a goal for all practicing pharmacists, and then provided advocacy for the endorsement of the Vision by their individual organizations. Following this initial success, the leaders appear to have given their exclusive attention to the urgent and important issues that were of priority for their individual organizations. There was no or very little follow-up to provide the strategies, action plans, and support needed to accomplish the laudable vision. The JCPP and its member organizations failed to attain the vision because they did not sustain the commitment and enthusiasm that existed when they wrote it in 2004. As 2015 approached and the failure was being recognized, the lack of transparency, excuses, updated revisions, and inaccurate descriptions of the contemporary daily responsibilities of practicing pharmacists (that most pharmacists and others do not consider credible), made an unfortunate situation worse.
And then it occurred to me, as if in a dream. I can't think of a better example to support my long-standing advocacy for our profession to establish a more effective, stronger, and unified organizational structure. When the JCPP and its member organizations worked together for a common purpose, they were successful in crafting an excellent vision. When the leaders of the associations went their separate ways, the initial commitment was neglected and the initiative failed. There would have been a better opportunity for success and progress if the JCPP member organizations were united in one organizational structure that was committed to the advancement of the entire profession, as well as the multiple practice roles and interests of its constituencies. The JCPP should suspend its revision of the PPCP and give priority to identifying a more unified and effective organizational structure for our profession.
I have been criticized for being in a dream world for even suggesting the possibility of a markedly different organizational structure for our profession. Readers have a choice of dream worlds to support, or better yet, provide recommendations for addressing issues that I have failed to identify. I also welcome responses from pharmacy leaders who have participated in JCPP decisions and activities from 2004 until the present time.
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