​ Do you think of your pharmacist as a health-care professional or a salesperson?

Internal emails from top Canadian chain drugstores show the pressures that pharmacists say they get from companies to push billable services in order to boost revenue.

The emails were shared with CBC’s Marketplace by pharmacists who are speaking out about increasing business pressures to perform extra services that can be billed to patients or to provincial governments. These services include medication reviews, flu shots, smoking cessation programs and food intolerance testing kits.

“I think as a pharmacist, it’s embarrassing,” Derek Jorgenson, a pharmacist and professor at the University of Saskatchewan’s College of Pharmacy and Nutrition, told Marketplace co-host Erica Johnson.

“I think it makes you feel like you’re not a health professional. It makes you feel like a door-to-door salesman or a used car salesman,” he said. “We as pharmacists didn’t go into this profession to do that.”

An ongoing investigation by CBC News and Marketplace found that some pharmacists feel that pressure to meet business quotas increases the likelihood that they could make mistakes. With no mandatory national tracking of pharmacy errors, there is little data on why and how often mistakes happen.

Several pharmacists spoke out about how the expectation to perform as many billable services as possible means that services like medication reviews are done quickly and not always directed at patients who need those services.

‘Continue driving those numbers’

The pharmacists approached Marketplace after the initial investigation to show how corporate pressures negatively affect their work.

“What we’re becoming is salesmen,” one former Rexall pharmacist told Marketplace.

Marketplace agreed to protect the identity of the pharmacists who spoke out because they fear retribution in the industry.

“They want us to sell med checks, flu shots, Hemocode tests, A1C tests, things that don’t cost the store anything, but make money for the store,” she said.

The pharmacists shared internal emails from management that discuss daily targets for medication reviews.

“Our ask is that you all work towards a goal of 7 per day per store unit,” one email from a Rexall regional manager reads.

Medication reviews are free for the patient, but the province pays for the service. Fees for medication consultations range from $52.50 to more than $150 for an initial assessment, depending on the type of review and province. There’s another lower fee for a followup review.

Another internal email shared with Marketplace says:

“Below, you will see how much your store needs to do next week in order to be ‘on track’ for the quarter so far. In order to help us get back on track, this Tuesday we will have a PFS [patient-focused services] focus day: The goal for Tuesday will be $500 or more PFS revenue for each store…. Reminder, each store must do a minimum of $500 in revenue.”

The email also details financial incentives for pharmacies that perform billable services.

“For every hemocode you do — the store will get $30 to use towards a meal or activity of their choice,” the email says.

Pharmacists also shared emails from Shoppers Drug Mart management.

“Be sure to remind your entire team as to your expectations with respect to MedsChecks. Are your assistants and technicians pre-printing the profile report? Are your staff pharmacists meeting your goals?” says one email from a Shoppers Drug Mart pharmacy operations specialist.

“Celebrate early success and challenge those on your team who aren’t contributing.”

Marketplace also obtained an internal chart where stores that were underperforming on medication reviews targets were highlighted in red.

“I encourage you all to continue driving those numbers,” one of the Shoppers Drug Mart emails reads.

The United Association of Pharmacist Franchisees, an organization that supports Shoppers Drug Mart franchisees, also confirmed that quotas are an issue.

“Let us be clear; associates have targets for professional services placed on them from corporate office,” the association wrote on its website.

The group says that these targets have consequences and are tied to bonuses based on district and provincial goals. The post also says that “associates who do not reach their targets are also potentially penalized financially.”

“There have also been some aggressive emails from some district managers to their district associates who were not achieving targets on professional services.”

Jorgenson said that medication reviews should be conducted only for patients who need that service and that it is unethical to use billable services as a means to drive revenue.

“As a health professional, as all health professionals, we’re trained to identify when our services are needed and how we provide them,” he says.

“I think a quota makes it feel like you must sell 10 cars today, or you’re going to be fired. And that may be reasonable in that industry, but as a health professional that’s not how we’re trained and that’s not how we’re trained to utilize the health system resources.”

Pharmacies respond

Marketplace reached out to the pharmacies about the concerns raised by pharmacists. Both Shoppers Drug Mart and Rexall declined to speak about these issues on camera.

Rexall denied that head office issues specific quotas for these services.

In a statement, Rexall wrote that: “Rexall and Rexall Pharma Plus pharmacies have a long and proud history of being a pharmacy first. Health care is the core of our business.”

Rexall says that pharmacists’ roles are about more than just dispensing medication, and that they play an important role in patient care by performing additional services such as immunizations, medication reviews, monitoring blood pressures and helping patients quit smoking.

“Our pharmacists use their professional judgment when a patient-focused service should be provided.”

Shoppers Drug Mart denied that the company has quotas for pharmacists or that pharmacists are punished for failing to perform a set number of billable services.

“We support our pharmacists to exercise their professional judgment in the delivery of appropriate care,” the statement reads.

“We do not exercise punitive measures to pressure our pharmacies to provide services that would be counter to optimal patient care. Working with our pharmacist-owners, we measure the delivery of pharmacy services so that we can plan appropriately for the labour needs required to deliver those services. This planning is based on industry-wide standards set for each type of pharmacy service.”

BC college cracking down

The College of Pharmacists of BC is set to become the first regulatory body in Canada to propose new regulations that would ensure that if quotas are in place they do not compromise patient safety.

According to a survey conducted by the college and the University of British Columbia, 59 per cent of pharmacists who work in chain drugstores who responded say they have quotas for medication reviews.

Surveyed pharmacists who said they have quotas were more likely to report inadequate staffing at their pharmacy and “a work environment that was not conducive to safe and effective patient care,” an executive summary of the survey said.