Independence Day and Independents Day
THE FUTURE OF PHARMACY:
THE SUICIDE OF OUR ONCE-NOBLE PROFESSION – UNLESS THERE IS A REVOLUTION!
http://pharmacistactivist.com/2022/July_2022.shtml
I had initially intended to include three briefer editorial commentaries in this July issue on the topics of the importance of independent pharmacies, more errors and terrible working conditions in chain pharmacies, and the continuation of the COVID-19 challenge and chaos. However, I did not sleep well last night. Although sleep prevailed, there were extended periods in which I laid awake thinking about the future of the profession of pharmacy. Was I dreaming? No! I had sufficient clarity of thought that I considered getting up and writing down the ideas that occurred to me lest I not remember them when I awakened this morning. But I did not get up and record them because the thoughts were so strong and clear that I knew I would not forget them. The result is that this commentary will focus on the essential role of independent pharmacists/pharmacies, the failure of most of the rest of our profession to recognize their importance, and the likely consequences absent a commitment and effort to take urgent actions – a REVOLUTION!
I have been greatly blessed by my studies and practice in the profession of pharmacy. Words can’t capture the joy I continue to derive from my friendships with so many dedicated pharmacists, the accomplishments of my former students who are now my friends and colleagues, recognizing the value of the medications, advice, and services provided by pharmacists for the benefit of their patients and society, and the excitement of knowing that there is still unlimited potential and value in expanding the role of pharmacists.
Victor Rossi taught the pharmacology courses that I took as an undergraduate pharmacy student; I consider him to be the “master teacher” whose combination of expertise, eloquence, and wit are unsurpassed in my more than 60 years of experience. We were faculty colleagues for many years and we stay in touch in our “retirements.” His skills have not diminished and, at his present age of 93, he is persistent in urging me to write an editorial about the future of pharmacy. I have declined to do that because of my lack of clarity and confidence in my ability to make such predictions. However, I have now overcome that reticence and Victor and my wife Suzanne are the only individuals whom I will ask to critique and suggest revisions in this commentary before I publish it.
Some of my comments in this editorial, although well-intended, are provocative and critical. They are made in the context of my recognition that I, personally, have not done enough to address the challenges described and to give back to our profession that has provided such a fulfilling experience and career for me and a comfortable lifestyle for our family. I need to do more!
Community pharmacy – Then
A pharmacy education and a license to practice provide an excellent foundation to assume a wide range of employment responsibilities within, concurrently with, or beyond the profession of pharmacy. Historically and today the number of pharmacists practicing in the community setting far exceeds the combined total of pharmacists employed in all other opportunities and settings.
Over a period of more than 150 years, the large majority of pharmacists developed their enthusiasm for and made their decisions to study pharmacy as a result of the positive influence of parents or a family friend who owned a community pharmacy and/or the employment experience as a high-school student in a community pharmacy. The latter situation was my personal experience. The commitment of the pharmacist owner and the other full-time and part-time pharmacists to know and serve their customers (prior to the time when we considered them our patients) and communities were impressive. Customers greatly appreciated and valued these positive relationships with the pharmacists and respectfully addressed them as “Doc” or greeted them by name. These personal qualities and services of pharmacists, combined with the “mysteries” of drug therapy for a high-school student who had not yet taken a chemistry course, as well as the willingness of the pharmacists to explain things to me, have motivated me and so many others to study pharmacy.
Community pharmacists have been the face and identity of the profession of pharmacy for the vast majority of the public, our legislators, and others. This is the reality, and does not diminish the importance of the roles of those pharmacists with employment responsibilities that are invisible or less visible to the public. Aside from my family, circle of friends, students, and pharmacists, few would know that I am a pharmacist, and the same is true for most other pharmacists who are not in community practice.
During this period of time there were no corporately-owned chain pharmacies and the “chain” pharmacies that did exist (e.g., Walgreens) were started and managed by pharmacists who were committed to the profession of pharmacy and serving their customers and communities.
Community pharmacy – Now
Over the past 50 years there have been dramatic changes in the profession of pharmacy and community pharmacy. Examples of progressive changes include customers becoming “patients” for whom pharmacists can provide information, counseling, advice, and monitoring of the use of increasingly complex medications, maintain patient profiles, perform drug utilization reviews, and provide immunizations.
Unfortunately, there have also been changes that have had a destructive impact on patient care and our profession. Examples include the establishment and growth of mail-order pharmacies, online pharmacies, and specialty pharmacies owned by corporations that provide medications from invisible pharmacists with whom either phone or other communications are rare occurrences. Health insurance companies and pharmacy benefit managers (PBMs) have seized the dominant roles in drug therapy decisions and compensation for the provision of medications to patients. The growth and number of corporately-owned chain pharmacies has been exponential as exemplified by CVS and Walgreens each owning approximately 10,000 pharmacies. Very few, if any, of the executives and other high-level decision-makers of these corporations are pharmacists and they often have no or limited experience in health care.
There are tens of thousands of excellent chain pharmacists. However, the egregious, understaffed, error-prone, metrics-dominated, and stressful working conditions that are determined by non-pharmacist executives prevent the availability of time for pharmacists to communicate with and advise customers. As a consequence, although some customers are observant and sympathetic to the pharmacist’s dilemmas (“you need more help”), many are angry, impatient and file complaints following long waits for prescriptions, appeals to purchase CarePass or participate in other company promotions, nuisance calls from the stores to obtain refills, immunizations, and other services they have not requested, etc. The frustration and anger of customers are often directed at the pharmacist and also include criticism of the high cost of drugs and increases in co-pays over which pharmacists have no control. Chain executives further exacerbate existing minimally-tolerable working conditions by reducing hours of pharmacist and technician staffing.
The strongest critics of chain pharmacies are their own pharmacists and other employees. Thousands vent their anger, burnout, mental health issues, and worse on social media. Chain pharmacists who are in a position to do so quit their jobs and sometimes leave our profession entirely. The turnover of pharmacy technicians is even higher, many of whom take positions at fast-food businesses with better pay and less stress.
Independent pharmacists
Independent pharmacies have been decimated by factors such as the non-negotiable policies/terms and abysmal compensation mandated by the largest PBMs, direct and indirect remuneration fees (DIRs) that are often based on generic drug utilization rates for which pharmacists have no knowledge or control, and the predatory tactics of large chain stores that steal patients and purchase independent and smaller local/regional chain pharmacies, sometimes under the threat of establishing their own pharmacies in the communities and forcing the already established pharmacies out of business.
Many independent pharmacists have sold their pharmacies to a large chain, often for an amount that is far less than their previous financial value. Others experiencing the challenge of financial survival have not been able to identify a purchaser and have had to close their pharmacies, possibly receiving pennies on the dollar for their inventories. For many, the higher previous value of their pharmacy was anticipated to be the equivalent of a pension that would be an important component of support following their retirement.
One consequence of these coinciding pressures has been a substantial reduction in the number of independent community pharmacies. Some of the independent pharmacist owners who continue have been able to combine imagination, creativity, and opportunity in their practices and services that have enabled them to not only survive but thrive under the present challenges. However, some others have succumbed to the “tyranny of the urgent” – and the perceived need to dispense more prescriptions faster and more efficiently. But this response is usually at the expense of the time and service these pharmacists can devote to providing personal attention and advice for individual patients. This is the single most valuable service that distinguishes the independent pharmacist from other stores and sources of medications, but some fail to recognize its importance with the result that it declines or disappears.
Customers using a busy, understaffed chain pharmacy usually have communication only with a technician, clerk, or cashier, but they may catch a glimpse of a pharmacist multi-tasking several counters behind the prescription counter where they are waiting. For this and other reasons previously identified, it is the independent community pharmacists who are the face and identity of pharmacy for the public. In addition, they represent the heart and soul of our profession. As my students and readers of The Pharmacist Activist are aware, I have been a strong advocate for independent pharmacy and have often voiced my belief that the ability of the entire profession of pharmacy to survive and thrive is inextricably linked to the ability of independent pharmacies to survive and thrive. I have been remiss in not recognizing at a much earlier time but independent pharmacists have also been the most influential and effective motivators and recruiters of young people to study pharmacy and enter our profession.
The profession’s “response”
The profession of pharmacy should feel greatly indebted to independent community pharmacists for the consistently excellent results for pharmacists in polls of the public regarding those in whom they place great trust for their integrity and ethical standards. HOWEVER, the profession of pharmacy has essentially ABANDONED independent community pharmacists.
Professional associations
With the noteworthy exceptions of organizations such as the National Community Pharmacists Association, American College of Apothecaries, Alliance for Pharmacy Compounding, many state/local pharmacy organizations, and wholesalers and buying groups of independent pharmacists, most national pharmacist membership organizations focus exclusively on the “specialty” practices and sites of their members while seldom, if ever, acknowledging the value of the profession, education, license, and the community pharmacists who provided the foundation that has enabled the development of newer and specialized roles and opportunities. The American Pharmacists Association (APhA) and other smaller organizations that purport to represent all pharmacists in the profession have provided some services that are of value for community pharmacists. However, they have FAILED in addressing the issues and individuals which are the most threatening for community pharmacists. These and other pharmacy organizations have developed some important initiatives to assist pharmacists in addressing well-being, burnout, resiliency, and mental health issues. At the same time they recognize the intolerable, error-prone working conditions many chain pharmacists experience, they REFUSE to challenge either privately or publically the executives of the large chains (e.g., CVS, Walgreens, Walmart, Rite Aid) who are most responsible for these working conditions.
To the contrary, these organizations show no hesitancy to accept revenue from these companies for meeting exhibits, unrestricted educational grants, and other programs. On some occasions they have even given awards to these same companies which are destroying the profession of pharmacy. Are there conflicts of interest? Are they afraid of losing members who work for these companies? It is significant that investigational journalist Ellen Gabler of the New York Times in several thoroughly-researched articles has been more effective than our pharmacy organizations in exposing medication/dispensing errors and the working conditions in chain pharmacies.
Our professional organizations act more often as competitors than colleagues in areas such as recruitment of members, development of continuing education programs and publications, and what some describe as the “sale” of credentials and accreditations. Some suggest that they are more committed to self-preservation and programmatic and membership growth than they are to addressing the issues of greatest importance to their members and being advocates for the entire profession of pharmacy that has enabled the opportunities they enjoy and from which they derive their livelihood. They fail to pursue the opportunity for greater strength and synergy if they were to function in a unified organizational structure, notwithstanding the myriad (and variable depending on the issue) “coalitions” of dozens of pharmacy organizations with an alphabet soup of acronyms that are more confusing than helpful for legislators and others to whom the requests and position statements are sent.
Colleges of pharmacy
Colleges of pharmacy and their faculties, as well as the American Association of Colleges of Pharmacy (whose preference is to be viewed as The Academy) also have done little or nothing to address the working conditions in chain pharmacies or to be advocates for and protect the financial survival of independent pharmacies. Many pharmacy students and some pharmacy faculty have never been inside an independent pharmacy or even know a pharmacist who works in one other than current or former students whom they might know. Some pharmacy faculty actively discourage or even belittle excellent students who wish to go into community practice, and suggest they would be wasting their expertise and potential if they do not participate in a residency or fellowship program or go into a graduate program. Some faculty have predicted the complete disappearance of independent pharmacies, and show no concern in doing so.
Many colleges of pharmacy do, however, solicit scholarships from the large chain pharmacies, as well as grants and gifts as large as amounts that would provide “naming rights” for a classroom, laboratory, building, or even the entire college of pharmacy. Are there conflicts of interest? The American Association of Colleges of Pharmacy is meeting later this month in Dallas. Following the meeting, I urge you to check its website and review the actions taken by the House of Delegates and identify the resolutions you consider most important for the profession and your responsibilities.
Pharmaceutical companies
Some of the largest pharmaceutical companies were founded by pharmacists, and achieved their early success that positioned them for subsequent dramatic growth and revenues because community pharmacists and hospitals purchased their products. Today, these same companies reject and ignore independent community pharmacists who, because they are the only participants in the prescription drug distribution system who are visible and accessible to patients, are the recipients of angry comments about the unconscionably high prices of trade name pharmaceuticals. After establishing the list price for these drugs the companies negotiate secret and unethical rebate deals with PBMs which they then blame for the high cost of the drugs.
Professional organizations of pharmacists, colleges of pharmacy, and pharmaceutical companies usually provide health benefits coverage for their employees that includes a prescription drug plan that is most often administered by CVS Caremark, Express Scripts, or Optum. These PBMs have engaged in fraud and deception and have had the most destructive impact of all on the profession of pharmacy that has forced many independent pharmacies to close, resulting in pharmacy “deserts” because the regions have an insufficient population base to attract a chain pharmacy with high profit expectations. Colleges of pharmacy then have the nerve to ask the same alumni who are victimized by the PBMs the colleges patronize to give generously to support their alma mater.
Selected relevant issues
In the late 1900s and early 2000s the available positions for pharmacists significantly exceeded the supply of pharmacists to the point that large chain pharmacies were offering signing bonuses to recruit pharmacists. Existing colleges of pharmacy increased their enrollments, even during the time of the transition to Doctor of Pharmacy programs that extended the duration of a pharmacy education from three professional years to four professional years plus at least two years of pre-professional studies. During this same period of time new colleges of pharmacy were established in numbers that bring the total to more than 140, approximately twice as many as the 72 that had remained constant for several previous decades. The larger number of colleges of pharmacy recruited many more student pharmacists and the number of pharmacy graduates markedly increased in a corresponding manner. This has resulted in a situation in which there are more pharmacists than there are positions in many parts of the country. Chain pharmacy executives seized this opportunity to cut the hours of pharmacists and technicians, reduce salaries for pharmacists, and terminate or otherwise force older and experienced higher-salaried pharmacists out of their positions to replace them at lower salaries with new graduates who were desperate for employment to start repaying college debts.
During the last several years there have been limited geographical areas in which there are shortages of pharmacists to the point that large chains have again provided signing bonuses (for a 2-year employment commitment) in certain regions, at the same time there is a surplus of pharmacists in most parts of the country. However, the reasons for these spot shortages differ from those of previous experiences. Some have resulted from the temporary greater demand for pharmacists to provide more immunization and other services necessitated by the COVID-19 pandemic, and include situations in which certain chains have closed earlier or for several hours on weekdays and entire days of a weekend. These usually unannounced temporary closings infuriate customers who arrive during “usual hours” for medications needed on a timely basis only to find the store closed and no guidance as to when they will be able to obtain their prescriptions. However, the more important and continuing reason for pharmacist shortages in some areas is the large number of pharmacists leaving their employment in chain pharmacies because of the working conditions, burnout, and stress that jeopardize their mental health.
Concurrent with these changes has been a decline in the number of high school graduates and a substantial reduction in the number of applications to study pharmacy and enrollments in colleges of pharmacy. To achieve even reduced enrollments, some colleges of pharmacy have reduced admissions standards and discontinued requirements for applicants to take the Pharmacy College Admission Test or the SAT or ACT. Enrollments and tuition revenues of some colleges of pharmacy have declined to the extent that faculty positions are being cut. At least one college of pharmacy has been “sold” to a larger university that wants to expand its programs in health care, several colleges that had accepted students and opened have closed, and several universities that intended to establish pharmacy programs have canceled those plans.
Some colleges of pharmacy that have taken pride in being collegial and not competitive in recruiting students are now intensely competing and actively promoting statistics that support their promotional efforts such as high employment placement rates following graduation and highly successful first-time NAPLEX pass rates. Other colleges dodge questions about NAPLEX pass rates and try to avoid disclosing them. These pass rates are publicly available but many applicants and their families are not aware of that. More colleges of pharmacy will close!
We have considered the marked decline in the number of independent community pharmacies and their positions for pharmacists. Few anticipated, however, that some large chain pharmacies would suspend their plans for geographical and numerical growth, and actually start closing their unprofitable pharmacies (e.g., CVS has announced plans to close 900 pharmacies over a period of 3 years and Rite Aid is closing a number of its pharmacies). As a consequence of mergers, acquisitions, and cost-reducing strategies by pharmaceutical companies, the number of positions for pharmacists in these organizations has also declined.
Who will study pharmacy?
The number of high-school students who are making college and career decisions is declining. Most colleges of pharmacy are experiencing reduced enrollments, resulting in increased competition in recruiting the best-qualified applicants. The typically higher tuitions of private colleges/universities add to their challenge in recruiting students.
Although the demographics and costs of a pharmacy education are important, there are other factors that influence decisions to study pharmacy that are even more important. Young people can not be expected to be aware of the multitude of opportunities one can pursue with an education in pharmacy. Therefore, their perspectives and opinions about a career in pharmacy are usually based on what they hear, observe, and learn about pharmacy and, in many cases, personally experience by working in a community pharmacy. Traditionally, community pharmacists have been the most influential and effective motivators and recruiters of young people to study pharmacy. But this is no longer the case!
The marked decline in the number of independent community pharmacists has resulted in the scarce availability of part-time positions for young people in these pharmacies. Even daughters and sons of parents who own independent pharmacies, who “grew up” working in the family’s pharmacy, may be sufficiently discouraged by what they experience and observe to be the influence on their parents and family relationships of long hours and the stress, problems, and challenges associated with the ownership and survival of an independent pharmacy. Indeed, many of these parents actively discourage their children from studying pharmacy and following in their footsteps.
There continue to be thousands of high-school and college-age young people who are employed in chain pharmacies. But what are they hearing, observing, and learning from these experiences? They observe first-hand the stressful and frantic working conditions and burnout, as well as the rapid turnover of technicians. They hear pharmacists say that they hate their district leader, employer, and sometimes even angry customers, and that they would never permit one of their own children to study pharmacy. They read the postings of these pharmacists on social media. They observe pharmacists resigning as soon as they can identify a better opportunity, or just quit to protect their mental health even before they can find another position. These experiences are strong disincentives to study pharmacy and they don’t. So who will study pharmacy?
The precipice of pharmacy’s suicide
There is a long list of external organizations, individuals, and factors that can be faulted as contributing to the desperate situation and challenges that the profession of pharmacy now faces. This is an exercise in futility. We must self-assess the actions, and lack of action, of the profession of pharmacy and acknowledge our own failures and that the arrival of the profession on the precipice of suicide is primarily self-inflicted rather than caused by external factors.
Many pharmacists will quickly exempt themselves from any responsibility or even any interest in the challenges identified. They typically are employed in innovative and progressive opportunities that are vastly different, and assumed to be unaffected by the problems of the “commoner” pharmacists whom they do not think have the vision, expertise, or motivation to aspire to the elite positions they hold. This is foolish and naïve reasoning, Very few outside of their families and colleagues know what they do, or even that they are pharmacists and their careers were launched with an education in pharmacy. When the foundation of pharmacy (i.e., community pharmacy) crumbles, the rest of the profession will soon follow. There is no immunity!
Health-system pharmacy is a distant second to community pharmacy with respect to the number of pharmacists employed. Some health-system pharmacists take great pride in distinguishing their professional roles and responsibilities from those of community pharmacists. There are some health-system administrators who have the vision to substantially expand the professional roles and numbers of positions for pharmacists. They are to be commended but these situations are the exception. In many health systems the pharmacists have traditional and routine responsibilities in providing medications for patients. Health-system pharmacy is at risk of becoming the next chain pharmacy. Some will be shocked at and quickly reject that thought. However, there are important similarities in the two settings in that the pharmacist Director of a health-system pharmacy does not have final decision-making and budgetary authority. It is the non-pharmacist CEO/Director of the health-care system that does in a manner analogous to the authority of the non-pharmacist CEO/Director of a chain pharmacy.
There is also no consolation in the recognition that other health professions including medicine are facing some of the same challenges as pharmacy. Many physicians experience the same intrusions in their practice roles and authority that pharmacists do, including those imposed by health insurance companies, PBMs (e.g., prior authorizations), and CEOs of health systems that own many physician practices. There is, however, an important distinction in that physicians are considered essential participants as “captains” of health care teams. Pharmacists may also consider ourselves to be essential participants but the reality is that some others do not concur. In the opinion of some, certain of the traditional responsibilities of pharmacists can be performed by technicians and robots. Consider also the rapid emergence of the roles of physician assistants and advanced-care nurse practitioners. Some states have provided the authority for nurse practitioners to have their own practices that are independent of a working relationship with a physician. Some physicians and medical associations are threatened by this possibility and strongly oppose it, as they have in opposing expansion of the roles of pharmacists in providing immunizations for children and in having prescribing authority for Paxlovid.
Our profession of pharmacy is on suicide watch! That will be our destiny UNLESS we start a REVOLUTION! I have not given up and am determined to be part of that revolution! My editorial in the August issue will include strategies and recommendations.
If I am asked…
If my grandchildren or other young people request my opinion as to whether they should study pharmacy, my response would be an emphatic YES, but with certain conditions. I would want to personally advise them on a continuing basis regarding specific opportunities for pharmacists that would enable them to obtain their full personal and professional potential and, if I am no longer available to provide that advice, I would choose someone to continue that guidance. And nothing would please me more than having the REVOLUTION once again provide opportunities for owning an independent community pharmacy if that would fulfill their professional, entrepreneurial, and financial aspirations.
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