The Panacea of Mail-Order Pharmacy – or Not

I noticed a little article in the New Mexico Senior Citizen News today. It’s all about the New Mexico VA Health Care System’s “faster, more efficient service – thanks to a new Refills by Mail program.” The article glows with praise about this system in which veterans will begin receiving their refills automatically. “Receiving refills by mail is so convenient when you think about the time some people would spend waiting in line at the pharmacy. Refills by mail is a win-win situation.”

The term “win-win” implies there will be benefits for all – both pharmacy staff and patients who use the pharmacy. “Currently, 40 percent of the work we do in our medical center pharmacy is refills. Our patients asked us to shorten wait times and we listened. This is one more example of our focus on veteran centered care.” At first glance, switching over to mail-order at the VA pharmacy sounds great. I mean, nobody wants to wait in line. And pharmacists would free up 40% of their time if the refills were handled by mail. Hey, I’m sold – and so are probably 90% of the seniors who pick up the News, and the author knows it. It’s imperative for any health care organization changing over to
mail-order pharmacy to sell it to its clients as a good thing. A time saver. A convenience. An improvement. When the author uses the words, “We listened” he wants you to hear the words, “We care.” But conflating mail-order pharmacy with a “focus on veteran centered care”? I wonder.

In pharmacies outside the VA system, mandated mail-order is becoming more and more common. Why? Because for the PBM’s (Pharmacy Benefit Managers) it’s extremely lucrative. PBM’s are middlemen that traditionally negotiate prices with pharmacies. They don’t necessarily pass discounts along to consumers. They take a piece of the action. In managing prescription drug programs for health insurance companies, PBM’s are always looking for ways to reduce costs and increase profits. One popular cost-saving strategy is mail-order. And they’ve taken it one step further: PBM’s are not only mandating the use of mail-order pharmacies, they’re mandating the use of mail-order pharmacies they own. David Kwasny, the president of Restat, a privately owned PBM, has said of this practice that “When we’re mandating a certain behavior and the person, the party mandating it owns that service, you’ve got to question that.”  Mr. Kwasny, I believe you’ve got a real talent for stating the obvious.

In February of this year, pharmacy lobbyists introduced legislation in New York to prohibit insurance companies from mandating the use of mail-order programs. They reason that the programs do away with the need to pay a pharmacist to counsel and administer the drugs. But Timothy C. Wentworth, senior executive at Medco Health Solutions, a PBM, says that mail-order patients can talk to a pharmacist over the phone, an optimal situation where they do not feel rushed or uncomfortable about asking questions, compared to the public atmosphere of retail pharmacy. And Mark Merritt, president and CEO of Pharmaceutical Care and Management Association, claims that mail-order pharmacies, run by computer systems, are guaranteed more accurate than a real, live pharmacist in checking for drug interactions and insuring proper dosages. Corporate CEO’s will no doubt continue to sing the praises of mail-order as long as profits continue to roll in but they cannot get away from one simple fact: mail-order pharmacy excludes patient-pharmacist interaction. Mail-order may save money but regular contact with a pharmacist can also save money, as well as increase quality of life. Pharmacists can, for instance, recommend programs for patients with chronic diseases. Let’s say a patient has multiple chronic, non-psychiatric conditions like Parkinson’s and cancer. He will have to take multiple drugs and will be at an elevated risk for depression. 25 or 30% of adult patients with depression commit suicide and the signs of depression are often contradictory, such as decreased energy with insomnia or anxiety along with disinterest in ordinary activities. He may also have vague, hard to interpret symptoms, such as aches and pains or changes in appetite. It’s crucial that this patient meet regularly with his pharmacist for assessment. Yet mail-order pharmacists often don’t have access to patient histories or prescribing physicians, so how can they build a solid foundation for consultation?

There’s lots of other problems with mail-order as well, like using the post office to distribute prescription drugs safely. The U.S. Postal Service concluded that a mere 8.4% of medication was distributed in temperature ranges recommended for safe storage of drugs. 65% are exposed to temperatures of 84-104 degrees. 25% are exposed to excessive temps over 104 degrees. 33%, shockingly, are exposed to temps over 170 degrees for as long as 21 days while being transported.

Like it or not, the health care industry in this country is run by corporations who are mandated, by law, to serve the interests of their shareholders. Devotion to the bottom line has led to the disturbing trend of cutting staff and personal service in order to preserve profits. But this approach is short-sighted. Western medicine seeks to find a cure once disease has set in, and our for-profit health care industry seeks to limit access to medical care and counsel to save money – a deadly combination. The average American citizen may be living longer than before, but he is also sicker. Illness is expensive. It seems a change in perspective is in order. It may never be written into law that a corporation must serve the general health and welfare of its customers, yet it stands to reason that preventive care and proper disease management would be simply cheaper than the way we do things now. If health care companies are motivated by neither concern nor compassion, pharmacists need to convince them that their expertise is just too expensive to waste.

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