What’s Up with Chain Pharmacies?

A news story early this month caught my eye: Walgreens pharmacists were walking out. As a former pharmacist, I’d noticed two earlier stories about chain pharmacy practice: One was an exposé in the Los Angeles Times about mistakes being made and the other at NPR.org on a walkout by pharmacists at CVS. The stories shared the same issue: Chain pharmacy practice is driven by the number of prescriptions delivered. It’s their primary metric. Everything else is window dressing.

Pharmacists disagree.

I’m a consumer of pharmacy services, and I am a retired clinical pharmacist who spent none of my four-decade practice in chain pharmacies. So I asked my pharmacy classmates (Pharm.D., UCSF ’72) about these stories. None had anything positive to say about the direction of chain practice. My recent conversations with other current practitioners were not reassuring either.

A couple of my classmates said:

“Unfortunately, the [LA Times] article is ‘right on‘ and correct. The big chains understaff and run sweat shops. The pharmacists are just running all day, multitasking, to the point of endangering patient safety. Very sad state of practice for all pharmacists. Big chains do not care about patient safety. It is all about corporate profits and market share. Not much else to say. A far cry from 1972.” —J.A.

“I don’t understand how this should surprise any of us.” —S.C.

Historically, the profession was defined as chemists who compounded salves, elixirs, and pills — not the same as tablets and capsules — from raw ingredients. As commercial patent medicines were increasingly marketed and accepted with scientific standardization (the mission of the FDA began in 1906), pharmacists became self-proclaimed “drug product experts” for the next half-century. Beginning in the 1960s though, schools of pharmacy changed their curricula to focus on patient care. New pharmacists were educated to do more than “count and pour, lick and stick.”

The incremental changes that occurred were expansions into services such as: the maintenance of patient drug histories, generic (less costly) drug substitution, private consultations, blood pressure booths, and vaccinations.

Pharmacists — particularly the new graduates — mostly welcome the changes, even though compensation steadfastly remains tied to dispensing products. It is safe to say none of the new practice enhancements were welcomed by chain pharmacy corporate officers. Their interest was to maximize the traditional reimbursement methods. Anything else was a distraction from efficiently providing the core product — the labeled prescription drug. Still, some newer features were tolerated because they attracted customers to the store.

During the pandemic, some stars aligned. Chain pharmacies were forced to allow their pharmacists to provide direct patient services. Huge national populations needed COVID prevention. The federal government primed the vaccine pump with dollars for research and development and payments for all willing patients to be vaccinated.

Tens of thousands of pharmacists were trained to give injections and already were well versed in providing medication instructions, precautions, and side effect warnings. And pharmacies were accessible across the country.

So, what’s going on now?

First, pharmacists are no longer avuncular middle-aged men wearing button-up smocks who take your prescription, fill (or compound) it, ring it up on the register, and give you a brief run-down on usage and side effects.

Now, each step is done by a different person, particularly in chain drugstores. It’s a production line, a prescription mill, with decentralized responsibility for accuracy and error-checking.

As well, the time-tested metric for prescription payment has increasingly focused on a tangible product, without regard to the other valuable aspects of the patient interaction. This is not unique to pharmacy practice. It is in play for physicians, nurses, dentists, and other health-care providers.

I use an independently owned pharmacy for my prescriptions, but last year I had a COVID booster, my first vaccine experience at a chain pharmacy. After answering some brief medical history questions and while the frozen vaccine vial was thawing, the pharmacist and I chatted in a semi-alcove about her practice. She had done a Midwest postdoctoral residency in pediatric pharmacy and was hoping for that type of practice, but none were available. To pay off her student loans, she took the CVS job and was still hoping to find a better practice situation. She made time to get complete histories from all of us vaccine seekers, although it was not a corporate priority.

Last month I received the Respiratory Syncytial Virus (RSV) vaccine at another CVS. The experience was starkly different. The pharmacist called out my name to confirm I was there, then went back into the shelves to prepare the injection. Customers standing in line to pick up prescriptions stared at me sitting in a chair off to the side.

The pharmacist returned and drew up the syringe. I explained my background, expecting a chat about pharmacy school. Her hurried responses: Boston, Northeastern University. No, she’d never heard of their professionally renown emeritus dean who I knew from another university in the 1970s. She was the only pharmacist there and needed to get back behind the counter.

This week I finished my seasonal vaccinations with a COVID booster and influenza injectionat a Rite Aid pharmacy, only out of convenience. This pharmacist recounted that corporate Rite Aid initially scheduled vaccination visits every 10 minutes. They realized (with strong input from practitioners) this did not allow time for even a basic interaction. Now appointments are every 20 minutes.

More and more, pharmacists in chain drugstore practices are demanding more staff to perform important patient-related services. And now, pharmacists and some technicians are withholding all of their work efforts to make their point.

As I read the news accounts, they are not (or minimally) about increased wages or benefits. The employees are generally well-paid. But an employee working at maximum safe capacity, cannot increase output, no matter how high the salary.

I will continue to get my prescriptions filled at the independent pharmacy I use now, and get my vaccinations at a chain store for my convenience. I advise readers to be their own best advocates.

• When you get a new prescription, one you have not taken before, be sure the pharmacist gives you the brief instructions for use and confirm that the drug is indicated for what you were expecting. If not, ask why.
• When you get a refilled prescription for a drug you have taken before, if it looks different than the last time, ask why.
• If the instructions on any prescription are different than what you remember from your prescriber’s visit, ask why. This may be difficult for many reasons, but it’s worth the conversation.

So: ask, ask, ask.