The Strange but Entirely True Tale of the Internet Pharmacy

The title of an article I came across online today said, “Walgreen’s Buys drugstore.com. Is This the Beginning of a Trend?” It’s obvious that Walgreen’s thinks so, because they paid $409 million for the purchase – 102% more than the company is valued at. “The move,” says Laura Heller at Slate.com, “lets the traditional retailer gain a foothold on the Internet that it’s been unable to do on its own.” There is some difference of opinion among online business pundits whether the move will be good for Walgreen’s bottom line or not, but while the retail giant maneuvers for ever better profit margins, how will this move affect pharmacists and consumers?

The Journal of Managed Care Pharmacy reported that implementation of Medicare Part D resulted in lower reimbursement rates and delayed prescription processing time that hit independent pharmacies hard. The National Community Pharmacists Association (NCPA) wrote that while 12.4% of its pharmacies were operating at a loss before Medicare Part D, the number nearly doubled to 22.9% after it began. In 2006, 1153 independent pharmacies went out of business. And the problem can’t be blamed on government-run programs alone. Of the three sources of reimbursement, Medicare Part D, Medicaid and managed care programs, pharmacists believe all to be inadequate.

As independent pharmacies began to close, the business of filling prescriptions shifted to the big retailers like Walgreen’s, CVS, Walmart and Rite-Aid, where reimbursement problems have translated to reduction of staff and services in their pharmacies. There are fewer pharmacists in the big stores and more pharmacy technicians. Pharmacists don’t have time to counsel patients and techs don’t have the skills, so little is offered to consumers in the way of drug education or management. Pharmacy Benefit Managers (PBMs) have been funneling patients into mail-order services to cut costs. Despite complaints to the NCPA from customers about shipping delays, price confusion, incorrect orders and lack of personal service, the trend is increasing. It appears that Walgreens’s and all of its 7600 retail locations see the handwriting on the wall: the brick and mortar pharmacy as a business model is failing. Self-service online drugstores are the next big thing. Woe to the rest of us.

I have written several times in this blog about the wasted resource of the neighborhood pharmacist. She knows more about drugs than many of the physicians who prescribe them. Doctors in managed care spend an average of seven minutes with each patient – not a lot of time to review drug regimens. My doctor writes out prescriptions and hands them to me. I’ve learned over the years to go home and do my own research about the drugs I take and more importantly, the ones I won’t take. But I live with a nurse. I went to nursing school myself. My boss is a pharmacist. You might say I’m pretty savvy when it comes to medical issues. But the average Joe who doesn’t understand that his liver and kidneys process every little pill his doctor prescribes is at a distinct disadvantage. He trusts that prescriptions are written to allay his symptoms and improve his health – maybe even to provide a cure. Most folks don’t know anything about the possible side effects or interactions of the drugs they take. No one tells them to make sure to throw away the out-of-date drugs in their medicine cabinets or to make sure they take their anti-biotics for the entire 10 days and why. Half of us in the U.S. take prescription drugs and at least 81% of us take at least one kind of pill every day. Most of us know little about the pills we take. We could start to undo some of the damage by utilizing our drug professionals. Pharmacists need a structure which allows them to do what they do best – teach us to use prescription drugs correctly. Sparingly. Effectively. Wisely. If there is no room in the current business model for this, then we need a better model. Internet pharmacy is not that model. Walgreen’s may say they’re serious about protecting your health when they tell you they’re “on the front lines of health care” with more than 8,000 “points of care across the country”, but those are just words. The action of buying drugstore.com speaks much louder.

Once a way is found to provide prescription drugs that actually benefits the consumer and the pharmacy profession, you can bet the big chain stores won’t be behind it. They view drug delivery as a profit stream; education and management therapy aren’t part of the picture. Consumers will see Internet pharmacy as a boon: free shipping and no lines – what’s not to love? So pharmacists, through their national organizations and educational institutions, are going to have to change the system themselves. Otherwise, the only person left behind the counter to talk to when your asthma inhaler causes heart palpitations will be a robot.

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Winning One for the Little Guy

Hooray! On March 22, 2011 the Supreme Court of the United States, considered by many as conservative and pro-corporate, decided one for the people! Or did they? At first glance, the unanimous decision to allow investors to sue the maker of Zicam cold remedies would seem to be a victory for the consumer. But alas, protection of users of the over-the-counter drug is not at the heart of this matter – protection of the shareholders is.

In 2004 the future seemed bright for Matrixx, the manufacturer of Zicam Nasal Gel and Cold Remedy Swabs. 70 percent of its income came from the products and stock was booming. In January the company predicted an 80 percent increase in earnings for the following year. But while cigars and champagne were passed around in the boardroom, one tiny issue remained unresolved. As early as 1999 Matrixx had received reports from at least three medical researchers about a possible link between Zicam and a loss of smell in at least ten patients. The company failed to disclose the reports and the Federal Drug Administration (FDA) investigation that resulted from them. But as 2004 progressed the lid came off; complaints increased and information was disclosed by the Dow Jones Newswires. Stock prices took a dive. Predictably, Matrixx issued a press release saying that no connection between Zicam and anosmia, or loss of smell, had been scientifically established and the stock rebounded, then fell again as further information suggesting a causal link surfaced.

By 2009 class action lawsuits on behalf of consumers were filed in California and Missouri. The FDA finally stepped in and issued a warning that sales and use of the product should be discontinued. By then some 130 reports involving anosmia and Zicam had been submitted to the agency. On June 16 of that year Matrixx issued a report emphasizing that “consumer safety is and always has been the company’s top priority.” The FDA action was “unwarranted,” said Matrixx representatives because, as everyone in the medical and scientific communities knew, “the most common cause of anosmia is the common cold.” Of course! Anyone with a cold and stuffed nose can’t smell a thing. Or taste anything, for that matter. But wait a minute. Consumers weren’t bringing lawsuits based on temporary cold-related cases of anosmia. These people had lost their sense of smell and, in some cases, their sense of taste after using Zicam – permanently. One woman who emailed Snopes.com with her Zicam story in 2006 reported an “intense, horrible burning in [her] nasal/sinus passages” and that “the skin on [her] face hurt to touch and [she] had pain and burning so that it hurt to move [her] head.” Ear, nose and throat specialists subsequently told her she had suffered “chemical trauma” to the olfactory nerve. She would be treated with high doses of Prednisone to reduce the inflammation but the damage, they said, was not likely to be reversed.

The 2009 FDA inspections ultimately revealed about 800 consumer complaints. According to Aboutlawsuits.com, inspectors estimated that 3.6 out of every 100,000 users experienced Zicam problems with loss of smell. Reports peaked in 2004, with 6.7 people complaining for every 100,000 units sold. Matrixx reps countered the statistics by reporting that 35 million retail units representing over 1 billion doses had been sold, demonstrating “both the safety and efficacy of Zicam…under conditions of ordinary use.” The issue that came before the Supreme Court rested on the statistical significance of the number of claims of harm. Matrixx couldn’t be expected to disclose reports filed by every Tom, Dick and Harry, their lawyers argued. Disclosing every little claim would harm the company, never mind the consumers. But in a 2011 story by NPR it was reported that, “The investors who bought stock…went to court, claiming that the company’s actions amounted to fraud – an attempt to keep the company’s stock price artificially high by failing to disclose material facts that, if known, would have affected the market.”

In her decision, Justice Sonia Sotomayor said that medical researchers and the FDA often reach initial conclusions based on evidence that is not statistically significant. Pharmaceutical companies don’t have to report every adverse side effect ever experienced, said Sotomayor. “Something more” is necessary. But the collective allegations in this case suggest “a significant risk to the commercial viability of Matrixx’s leading product. Matrixx elected not to disclose reports of adverse events not because it believed they were meaningless but because it understood their likely effect on the market.”

While the good Justices have found the stock portfolios of investors to have been adversely affected by Zicam, what about the damage to delicate nasal tissues of the consumers? If Goliath has indeed slain Goliath in the highest court in the land, how will David fare? Perhaps a requirement making drug companies report adverse reactions to their products in order to protect investors will, in turn, protect those who buy the products. Or maybe what we have here is just a case of some fat cat investors taking big-money drug makers to court and coming out on top. Perhaps hoping that the Court’s decision on behalf of those investors will also benefit consumers is like hoping for tax cuts for the wealthy to trickle down to the working class: pure voodoo.

Sally, We Hardly Knew Ye

Sally Field is one of my favorite actresses. Since her series, “The Flying Nun” began airing in 1967 she has been part of the American culture. I cried with her during “Steel Magnolias”, cheered her on when her inner child popped out to accept the “Best Actress” Oscar for “Norma Rae” (“You like me. You really like me!”), and was fascinated by her complex and nuanced portrayal of a physician with bipolar disorder on ER. I grew up watching Sally Field on screens both big and small and she sort of feels like a friend in the way that familiar celebrities sometimes do. So when she began appearing in commercials for a popular osteoporosis drug, I became genuinely concerned for her health. Is it possible that the Flying Nun is on a crash course with Boniva?

Boniva is in a class of drugs known as bisphosphonates, along with other osteoporosis drugs like Fosamax and Acontel. Bisphosphonates are very similar to the chemicals used to clean calcium deposits out of pipes by acting as a kind of calcium binder or ‘magnet’. Researchers figured they could be used clinically as well, by attracting calcium into bone. The first report of the biological characteristics of bisphosphonates was published in 1968. At that time, scientists discovered that bisphosphonates have a marked ability to inhibit bone resorption. In other words, Boniva and other drugs in its class severely inhibit the body’s ability to discard old bone. Bones are ‘modeled’ as we grow and ‘remodeled’ when we are adults; bits of old bone are discarded and new bits filled in, keeping our bones healthy. When old bone is not replaced as quickly as it is disposed of, diseases like osteoporosis take hold. It is necessary for bone resorption to occur in order to trigger bone formation. But once Boniva is melded into the skeletal system, it does in fact interfere with the shedding of old dead bone. Rather than ‘die off,’ old, weak bone cells remain, interfering with growth of new bone cells, and causing the rest of the skeletal system to become weak. Bone scans may show the growth of new bone after using bisphosphonates for a while, but studies are showing that the new bone is brittle. The New York Times article, “Drugs to Build Bones May Weaken Them,” states that Boniva users “show a rare type of leg fracture that shears straight across the upper thighbone after little or no trauma. Fractures in this sturdy part of the bone typically result from car accidents, or in the elderly and frail. But the case reports show the unusual fracture pattern in people who have used bone-building drugs called bisphosphonates for five years or more.” Sally puts her 65 year-old body through the paces at the gym, plays with her dog and jumps rope with her grandchildren in Boniva commercials, selling us on the idea that her bones are stronger after taking it. In reality her bones are becoming more and more fragile over time. If this isn’t bad enough, Boniva is also linked to a condition known as ‘dead jaw’ where the jaw bone literally dies and can also include other gruesome side effects like loose teeth, poor healing gums, numbness, pain and exposed jawbone and drainage. If any of these symptoms develop, Sally, you won’t get so much as a role as the dancing tomato on a ketchup commercial.

In addition to Boniva, maybe you’ve heard of Zetia? Accutane? Bextra? Or perhaps you’ve taken Crestor or Vioxx? These are just a few of the other dangerous drugs being litigated at the moment. Pharmaceutical companies develop them, the Food and Drug Administration (FDA) approves them, TV advertises them, physicians prescribe them and you and I take them. Sometimes we get sicker and maybe we die. Apparently the FDA takes the position that unless a substance is known to be a health hazard it can be used until it’s proven to be unsafe. So whether we’re talking about bisphenol-A in our plastic bottles, genetically modified foods or bisphosphonates, the American public is just a large sample in a long-term scientific study. Once diseases or deaths are discovered five or ten years into some drug or food experiment and an ingredient or process is finally banned as unsafe, lawyers and corporations have already made their millions. (Here’s something that will make your jaw drop before it rots off: Boniva costs an astounding $400 a pill.) Unproven new ingredients are then developed or old ones are repackaged as something new and the process begins all over again.

Drug companies want to sell you their wares, free and unfettered, so they donate to campaign funds of politicians who make “regulation” of the food and drug industries a dirty word and underfund the FDA so oversight is nearly impossible. Why isn’t the FDA doing its job, you ask? Because it’s been neutered and its testicles are sitting in a jar on some Congressperson’s desk.

I believe nothing will change with the way drug companies do business until lots (and I mean LOTS) of us rear up on our hind legs and growl, “Enough!” As for Sally Field, well, celebrities do advertisements because they pay well. Really well. But I trusted those chubby little cheeks of yours, Sally. I really did.

So You Want to Be a Pharmacist?

Who wouldn’t be happy to be a pharmacist? They’re prestigious professionals of the medical field – white coat, license, good pay and benefits. What’s not to love? But stress within the profession is increasing and with big chain pharmacies gobbling up the independents at an alarming rate, it’s not hard to understand why.

The good news: US News & World Report names pharmacy as one of the best careers of 2009. They cite the expanding role of pharmacists, high demand, increasing number of pharmacy schools and good salaries as reasons for their nomination.

The bad news: Pharmacy falls off the list when US News &World Report releases their article about the 50 Best Careers of 2011. No explanation offered.

The good news: In 2004 the journal P & T reports that 80% of pharmacists in independent settings and 78% of pharmacists in hospital settings are satisfied with their jobs.

The bad news: In 2004 P & T reports that only 53% of pharmacists are satisfied with their jobs in retail settings.

The good news: Pharmacy benefits for some 200 million Americans are administered by pharmacy benefit managers (PBMs), third party companies that use their clout to obtain lower prices and benefits for customers like drug discounts, rebates and mail-order services.

The bad news: Independent pharmacies as a group are blocked by antitrust laws from negotiating collectively with the PBMs. They sign contracts with the big three, Medco Health Solutions, Caremark and Express Scripts, but have little to say about the terms. PBM schemes to save money, such as mail-order drug services, are driving independents out of business. Big chains cut staff and personalized service to keep up.

The good news: 60% of US pharmacists are employed in retail outlets like Walgreen’s (5000 stores), CVS (4100 stores), Walmart, Target, Rite-Aid, etc., that provide money-saving offers to increase their customer base. That means many $4.00 prescriptions, 90-day supplies of prescribed drugs, mail-order services, 15 minute prescription fill guarantees and drive-through convenience for you and me.

The bad news: The National Community Pharmacist Association (NCPA) has logged thousands of complaints from customers who are frustrated by the lack of service when they’re forced into mail-order service as a cost-cutting measure. They’re aggravated by shipping delays, confusion on prices, incorrect orders, late refills and the inability to reach a human being on the phone at their PBM. Naturally, when there’s a problem with mail-order, customers want retail pharmacists to fix it. Lean staffing practices mean pharmacists already have only 3 minutes to dedicate to each prescription. Reported errors make up about 3% of the total, meaning actual error rates are much higher. Now Rite-Aid is advertising 15 minute guarantees. Are they kidding?

The good news: Big chain stores offer competitive pricing on drugs. Some stores are open 24 hours. When visiting these stores customers can also shop for groceries, clothing and household items. There’s LOTS of these stores in urban areas; they’re easy to get to and have ample parking. A recent Walgreen’s commercial depicts that renewing a prescription is so easy, you can do it on your cell phone while mountain climbing in sub-zero temperatures.

The bad news: Big chain pharmacy has a narrow focus on efficiency, reducing their in-house pharmacies to assembly lines. CVS pharmacies in Georgia have been fined by the state’s Pharmacy Board for not having enough pharmacists on staff, which means your prescriptions are being overseen by pharmacy techs instead, with 2 years of education. Pharmacists don’t have time to counsel their customers, meaning there is a gap between the proposed expanded role for pharmacists and reality.

More bad news: Big chain pharmacies are plagued by high pharmacy staff turnover rates and low job satisfaction levels. Pharmacists in the big stores work long shifts on their feet without lunch breaks. Their jobs are largely about navigating through conflicting rules of the various insurance companies as opposed to serving the needs of patients. Increased use of pharmacy techs by the employers means more management responsibility for the pharmacist while their wage/benefit packages are driven lower. Why get into this lousy business, anyway?

The good news: Pharmacists still have the ability to make positive changes in their profession by changing their focus. Many pharmacists like to think of themselves as non-political and they’re notorious for not organizing. Letters to the American Pharmacists Association on critical issues from large numbers of pharmacy professionals DO have impact, as do emails and phone calls to state boards of pharmacy and lobbying efforts to pressure state politicians on matters of pharmacy legislation. Medication therapy management programs may seem like distant dreams until groups of concerned pharmacists come together to find ways of making them happen. And instead of watching independent pharmacies go the way of the dinosaur, pharmacists need to capitalize on what makes service at the smaller stores different – why someone like me should never find a reason to patronize a big chain store for my prescriptions again. In short, show the world why the neighborhood pharmacist is indispensible to every healthcare team and every customer. Proclaim the value of personalized pharmacy service and education from every rooftop! Take this story, for example: one night at an independent pharmacy in Kansas, pharmacist Brian Caswell sent a customer to the hospital after he had come in complaining that he didn’t feel well. “I took his blood pressure and knew something wasn’t right,” Caswell says. “He came back days later and says he could have dropped dead from cardiac arrhythmia. Now I have a customer for life. Can mail-order do that?”

Why That Prescription Takes So D**N Long to Fill And Why It’s Not Your Pharmacist’s Fault, After All

I’m not a pharmacist in real life – I just write about them in this blog. I understand the issues that affect them from a layman’s point of view and must confess that when I go to the pharmacy I get just as impatient as everybody else. So, for all of us who just can’t understand why we have to wait so long to have a prescription filled (after all, how long can it take to put some pills in a bottle?) my fellow blogger DrugMonkey, Master of Pharmacy, offers the following explanation:

 Your Pharmacist May Hate You – the answer as to why your prescription takes so damn long to fill…and evidence of how drugstore workday life warps the mind.

 You come to the counter. I am on the phone with a drunk dude who wants the phone number to the grocery store next door. After I instruct him on the virtues of 411, you tell me your doctor was to phone your prescription in to me. Your doctor hasn’t, and you’re unwilling to wait until he does. Being in a generous mood, I call your doctor’s office and I am put on hold for five minutes, then informed that your prescription was phoned in to my competitor on the other side of town. Phoning my competitor, I am immediately put on hold for five minutes before speaking to the clerk, who puts me back on hold to wait for the pharmacist. Your prescription is then transferred to me, and now I have to get the two phone calls that have been put on hold while this was being done. Now I return to the counter to ask if we’ve ever filled prescriptions for you before. For some reason you think that “for you” means “for your cousin” and you answer my question with a “yes”, whereupon I go to the computer and see you are not on file.

 The phone rings.

 You have left to do something very important, such as browse through the monster truck magazines, and do not hear the three PA announcements requesting that you return to the pharmacy. You return eventually, expecting to pick up the finished prescription…

 The phone rings.

 …only to find out that I need to ask your address, phone number, date of birth, if you have any allergies and insurance coverage. You tell me you’re allergic to codeine. Since the prescription is for Vicodin, I ask you what exactly what the codeine did to you when you took it. You say it made your stomach hurt and I roll my eyes and write down “no known allergies”. You tell me…

 The phone rings.

 …you have insurance and spend the next five minutes looking for your card. You give up and expect me to be able to file your claim anyway. I call my competitor and am immediately put on hold. Upon reaching a human, I ask what insurance they may have on file for you. I get the information and file the claim, which is rejected because you changed jobs six months ago. An asshole barges his way to the counter to ask where the bread is.

 The phone rings.

 I inform you that the insurance the other pharmacy has on file for you isn’t working. You produce a card in under ten seconds that you seemed to be unable to find before. What you were really doing is hoping that your old insurance would still work because it had a lower co-pay. Your new card prominently displays the logo of Nebraska Blue Cross, and although Nebraska Blue Cross does in fact handle millions of prescription claims every day, for the group you belong to, the claim should go to a company called Caremark, whose logo is nowhere on the card.

 The phone rings.

 A lady comes to the counter wanting to know why the cherry flavor antacid works better than the lemon cream flavored antacid. What probably happened is that she had a milder case of heartburn when she took the cherry flavored brand, as they both use the exact same ingredient in the same strength. She will not be satisfied though until I have confirmed her belief that the cherry flavored brand is the superior product. I file your claim with Caremark, who rejects it because you had a 30 day prescription for Vicodin filled at another pharmacy 15 days ago. You swear to me on your mother’s…

 The phone rings.

 …life that you did not have another Vicodin prescription filled recently. I call Caremark and am immediately placed on hold. The most beautiful woman on the planet walks by and notices not a thing. She has never talked to a pharmacist and never will. Upon reaching a human at Caremark, I am informed that the Vicodin prescription was indeed filled at another of my competitors. When I tell you this you say you got hydrocodone  there, not Vicodin. Another little part of me dies.

 The phone rings.

 It turns out that a few days after your doctor wrote your last prescription, he told you to take it more frequently, meaning that what Caremark thought was a 30 day supply was indeed a 15 day supply with the new instructions. I call your doctor’s office and am immediately put on hold. I call Caremark to get an override and am immediately placed on hold. My laser printer has a paper jam. It’s time for my pharmacy tech to go to lunch. Caremark issues the override and your claim goes through. Your insurance saves you 85 cents off the regular price of the prescription.

 The phone rings.

 At the cash register you sign…

 The phone rings.

 …that you received a copy of my HIPAA policy and that I offered the required OBRA counseling for new patients. You remark that you’re glad your last pharmacist told you you should’t take over-the-counter Tylenol along with the Vicodin, and that the acetaminophen you’re taking instead seems to be working pretty well. I break the news to you that Tylenol is simply a brand name for acetaminophen and you don’t believe me. You fumble around for two minutes for your checkbook and spend another two minutes writing out a check for four dollars and sixty-seven cents. You ask why the tablets look different than those you got at the other pharmacy. I explain that they’re from a different manufacturer. Tomorrow you’ll be back to tell me they don’t work as well.

 Now imagine that this wasn’t you at all, but the person who dropped off their prescription three people ahead of you, and you’ll start to have an idea why….your prescription takes so damn long to fill.

 (From this day forward I promise to give my pharmacist the benefit of the doubt and complain about my HMO instead! – cvh55)