Lately we have heard stories of Pharmacists not doing their job correctly. To be exact, in a survey of a sample of pharmacies, it was discovered that medications that are kept in the pharmacy but did not need a prescription, there was insufficient or completely absent counselling on behalf of the pharmacist. These medications are in a special class in that they can only be sold in a pharmacy, behind the counter of the dispensary, and the customer must ask for the medication in order to be screened for interactions with existing medications and medical conditions, as well as proper use of the medication so that it is safely used and gives the best results.
Although there were arguments that the sample size used in this observation was too small to make an overall conclusion, just 50 pharmacies, and that the study was not scientific, showing even one pharmacy not counselling this type of medication is not good. As pharmacists we don’t shoot for a certain percentage of jobs done correctly across the country in the run of a day. We more importantly look at any incidence of improper counselling and try to better ourselves by looking at why we didn’t do our job correctly. Undoubtedly spurred on by a few recent reports of dispensing errors across the country, this survey began in BC and spread across the country based on the results in that one province. Trust me, when a pharmacist makes a mistake, it hits them like a ton of bricks, regardless of the outcome.
This nationally broadcast report was fuelled by a week long buildup that caught the eyes of pharmacists and general public alike. Word began to spread in the New Year about the story and certainly when it finally came to air, there was a huge reaction from those who watched it. Many pharmacists chimed in. Initially claiming unfair reporting in that it made pharmacists look completely inept. Others claimed that the story completely avoided the good that pharmacists do that is totally ignored for the most part. This was followed by examples of what we do as pharmacists every day. The reporter afterwards quickly claimed that the show was more about quotas imposed on pharmacists to increase script count than exposing pharmacists not doing their job correctly. It was certainly a perception of mine leading up to the program and certainly after watching the program that the latter was the case.
As someone that works for an independent in a small community, the concept of pressure imposed by quotas for increased prescription count is definitely foreign to me and one I must admit I had never heard of before. Pharmacists interviewed for the program claimed that this pressure to increase script count was responsible for other parts of their job slipping, including counselling these behind the counter medications and focussing properly on the filling and checking process. Let’s suppose this were true, and maybe it is. Then obviously it is something eroding pharmacy that needs to be addressed. These pharmacists interviewed pointed to the problem of non pharmacists now able to own pharmacies – something new over the last couple of decades. The profession of pharmacy is certainly not against change, but the change we have seen over the last 20 years has absolutely lead to great things, but in some cases has also lead to the erosion of the profession.
Before I graduated from the College of Pharmacy in 1993, things were strict. You kept things professional by not being able to advertise “free prescription delivery”, you couldn’t connect any incentive to a prescription like “points” for your prescription purchase or bonuses for transferring your prescription file to a pharmacy, you couldn’t say “accurate prescription filling” because it was unprofessional and implied someone else had inaccurate prescription filling, among other strict rules. Gradually, we saw big box stores start to include incentives to their employees when they had their prescription filled at their banner, then drug plans that are affiliated with the pharmacy with restrictions that you are covered when you get your prescription filled only at that pharmacy chain and no other. While on the subject of third party plans, in my opinion the most dramatic effect overall in the pharmacy business today, we have seen a very gradual undermining of the pharmacy business because dispensing fees and reimbursement to pharmacy from the third party plan has not grown with what is reality in dispensing. Dispensing has become a volume business in order to show a real profit. In fact we are starting to see decreases in dispensing fees from third party plans. In a lot of ways I feel these plans are a part owner in my business.
A sweeping move initiated by provincial governments across the country was a huge hit to the bottom line of pharmacies, like Nova Scotia’s Fair Drug Price Act. A move that seemingly made sense to the general population in that it aimed at lowering prescription prices by coming up with an imaginary dollar value for various popular generic medications, regardless of what the pharmacy paid for it. This move came about from the practice of generic companies giving rebates for purchases, a common practice in many types of business. The government saw this as their money. These were the main dollars we used to run the programs of our pharmacy and the dollars we used for donations and community programs that came to us for help. Very quickly this money was gone. In effect, this attempt by the government to lower prescription drug prices was accomplished on the backs of the pharmacies in the provinces. Our communities are now realizing the effect of lack of income in their community pharmacies. Before too long, we saw other third party plans jump on this bandwagon, and gone were more dollars we used to run health programs we conceived on our own for the health our community.
Enter the expanded scope of practice. We as pharmacists were allowed now to write prescriptions in certain cases of minor ailments, extend existing prescriptions, do med reviews, injections, adaptation of prescription, and order and interpret lab tests. The reason was we can charge for these services to make up for what we were losing on the other end with rebates. Definitely this is an honourable theory: make money for actually doing something that helps with the health of our patients. The problem being that there was now no money to run these new services anymore and most plans weren’t on board with paying for them .
One might argue, “then why not just drop your affiliation with third party plans?” Then we could set our own prices bases on our own pharmacy needs and staff levels . Small town low volume stores could have better control over their income and not allow third party plans to control what they earn on a prescription. Instead of getting paid 12 dollars for a prescription that costs 15 dollars to fill, you could charge what you paid for the drug and a fee that allows the dispensary to make money on its own regardless of the front shop. Well we do this because it allows our patients to afford their medications and they probably fill more prescriptions for their health when they have coverage, not to mention that all pharmacies not dropping plans means patients shop for pharmacies that take these plans.
This brings us back to the original issue of why are we dropping essential counselling and why are we too busy to catch interactions? Well perhaps the pressure we should be looking at isn’t the pressure to fill more prescriptions, it’s the pressure imposed by third party plans on the pharmacy whereby they don’t make enough on each prescription to pay for itself in the first place. Maybe this is the reason for the “quota” being imposed on pharmacies to fill more. The lack of reimbursement forces any pharmacy to scratch for more prescriptions since they cannot afford to hire the staff to run these extra programs and give time to the pharmacist to do their work of not only bettering health, but preventing harm from meds.
To top off the issue of missed interactions because of lack of time, consider the thought process involved with each and every prescription when the possibility of the patient dying from the medication exists each time a prescription is filled. The side effect of any medication is death and there are so many side effects and potential warnings on any given medication it would take an hour to explain them all to each patient. On top of that, the sheer volume of prescription interactions with other meds or disease states makes the evaluation of these interactions an art that is not just based on book smarts, but also on clinical experience. If there is a 0.00001 chance of a dangerous interaction occurring do you call the doctor, alert the patient and change the drug? Is the evaluation of these interactions a black and white science or is it based on followup with the patient on their overall health and history. Recently I wrote a blog on a type of interaction called prolonged QT interval ( https://stonespharmasave.com/blog/?p=694 ) that describes the complex evaluation involved with just one interaction. There are thousands of such interactions to evaluate for each fill and you reset your brain when you fill the next prescription. If I give you a prescription there is a very slight chance you might leave the pharmacy, take the medication, have an adverse reaction or interaction with another medication and die. Perhaps I will be on the evening news for not telling the patient this. Do I tell you this? Not necessarily. But if I evaluate the probability of this reaction occurring then I am in a better position to act on it. When we take off in an airplane do we sign off on the fact that it might crash? There is inherent risk in taking any medication. It’s our job to make sure you have the best possible medication and outcome from that medication.
Getting back to the lack of counselling in these behind the counter medications – guilty. We accept that. The more pharmacy and pharmacies are left to be run by corporations (big box stores and third party plans) and not pharmacists, the more and more this profession will erode and show up on more undercover specials.