The Atlanta Journal-Constitution
Tragic price for profits at pharmacy chains?
Understaffed and under pressure to maximize profits, pharmacy chains may be increasing risks for patients.
Understaffed and under pressure for profits, chains are criticized for prescription practices that may be putting patients at risk.
For Alyssa Watrous, the medication mix-up meant a pounding headache, nausea and dizziness. In September, Watrous, a 17-year-old from Connecticut, was about to take another asthma pill when she realized CVS had mistakenly given her blood pressure medication intended for someone else.
Edward Walker, 38, landed in an emergency room, his eyes swollen and burning after he put drops in them for five days in November 2018 to treat a mild irritation. A Walgreens in Illinois had accidentally supplied him with ear drops — not eye drops.
For Mary Scheuerman, 85, the error was discovered only when she was dying in a Florida hospital in December 2018. A Publix pharmacy had dispensed a powerful chemotherapy drug instead of the antidepressant her doctor had prescribed. She died about two weeks later.
The people least surprised by such mistakes are pharmacists working in some of the nation’s biggest retail chains.
In letters to state regulatory boards and in interviews with The New York Times, many pharmacists at companies like CVS, Rite Aid and Walgreens described understaffed and chaotic workplaces where they said it had become difficult to perform their jobs safely, putting the public at risk of medication errors. They struggle to fill prescriptions, give flu shots, tend the drive-through, answer phones, work the register, counsel patients and call doctors and insurance companies, they said — all the while racing to meet corporate performance metrics that they characterized as unreasonable and unsafe in an industry squeezed to do more with less.
“I am a danger to the public working for CVS,” one pharmacist wrote in an anonymous letter to the Texas State Board of Pharmacy in April.
“The amount of busywork we must do while verifying prescriptions is absolutely dangerous,” another wrote to the Pennsylvania board. “Mistakes are going to be made and the patients are going to be the ones suffering.”
State boards and associations in at least two dozen states have heard from distraught pharmacists, interviews and records show, while some doctors complain that pharmacies bombard them with requests for refills that patients have not asked for and should not receive. Such refills are closely tracked by pharmacy chains and can factor into employee bonuses. Michael Jackson, chief executive of the Florida Pharmacy Association, said the number of complaints from members related to staffing cuts and worries about patient safety had become “overwhelming” in the past year.
The American Psychiatric Association is particularly concerned about CVS, America’s eighth-largest company, which it says routinely ignores doctors’ explicit instructions to dispense limited amounts of medication to mental health patients. The pharmacy’s practice of providing three-month supplies may inadvertently lead more patients to attempt suicide by overdosing, the association said.
“Clearly it is financially in their best interest to dispense as many pills as they can get paid for,” said Bruce Schwartz, a psychiatrist in New York and the group’s president.
A spokesman for CVS said it had created a system to address the issue, but Schwartz said complaints persisted.
Regulating the chains — five rank among the nation’s 100 largest companies — has proved difficult for state pharmacy boards, which oversee the industry but sometimes allow company representatives to hold seats. Florida’s nine-member board, for instance, includes a lawyer for CVS and a director of pharmacy affairs at Walgreens.
Aside from creating potential conflicts of interest, the industry presence can stifle complaints. “We are afraid to speak up and lose our jobs,” one pharmacist wrote anonymously last year in response to a survey by the Missouri Board of Pharmacy. “PLEASE HELP.”
Officials from several state boards told The Times they had limited authority to dictate how companies ran their businesses. Efforts by legislatures in California and elsewhere have been unsuccessful in substantially changing how pharmacies operate.
A majority of state boards do not require pharmacies to report errors, let alone conduct thorough investigations. Most investigations focus on pharmacists, not the conditions in their workplaces. In public meetings, boards in at least two states have instructed pharmacists to quit or speak up if they believe conditions are unsafe. But pharmacists said they feared retaliation, knowing they could be replaced.
The industry has been squeezed amid declining drug reimbursement rates and cost pressures from administrators of prescription drug plans. Consolidation, meanwhile, has left only a few major players. About 70% of prescriptions nationwide are dispensed by chain drugstores, supermarkets or retailers like Walmart, according to a 2019 Drug Channels Institute report.
CVS garners a quarter of the country’s total prescription revenue and dispenses more than a billion prescriptions a year. Walgreens captures almost 20%. Walmart, Kroger and Rite Aid fall next in line among brickand-mortar stores.
In statements, the pharmacy chains said patient safety was of utmost concern, with staffing carefully set to ensure accurate dispensing. Investment in technology such as e-prescribing has increased safety and efficiency, the companies said. They denied that pharmacists were under extreme pressure or faced reprisals.
“When a pharmacist has a legitimate concern about working conditions, we make every effort to address that concern in good faith,” CVS said in a statement. Walgreens cited its confidential employee hotline and said it made “clear to all pharmacists that they should never work beyond what they believe is advisable.”
Errors, the companies said, were regrettable but rare; they declined to provide data about mistakes. The National Association of Chain Drug Stores, a trade group, said “pharmacies consider even one prescription error to be one too many” and “seek continuous improvement.” The organization said it was wrong to “assume cause-effect relationships” between errors and workload.
The specifics and severity of errors are nearly impossible to tally. Aside from lax reporting requirements, many mistakes never become public because companies settle with victims or their families, often requiring a confidentiality agreement. A CVS form for staff members to report errors asks whether the patient is a “media threat,” according to a photo provided to The Times. CVS said in a statement it would not provide details on what it called its “escalation process.”
The last comprehensive study of medication errors was over a decade ago: The Institute of Medicine estimated in 2006 that such mistakes harmed at least 1.5 million Americans each year.
Too much, too fast
The day before Wesley Hickman quit his job as a pharmacist at CVS, he worked a 13-hour shift with no breaks for lunch or dinner, he said.
As the only pharmacist on duty that day at the Leland, N.C., store, Hickman filled 552 prescriptions — about one every minute and 25 seconds — while counseling patients, giving shots, making calls and staffing the drive-through, he said. Partway through his shift the next day, in December 2018, he called his manager.
“I said, ‘I am not going to work in a situation that is unsafe.’ I shut the door and left,” said Hickman, who now runs an independent pharmacy. He felt the multitude of required tasks distracted from his most important jobs: filling prescriptions accurately and counseling patients. He had begged his district manager to schedule more pharmacists, but the request was denied, he said.
CVS said it could not comment on the “individual concerns” of a former employee.
With nearly 10,000 pharmacies across the country, CVS is the largest chain and among the most aggressive in imposing performance metrics, pharmacists said. Both CVS and Walgreens tie bonuses to achieving them, according to company documents.
Nearly everything is tracked and scrutinized: phone calls to patients, the time it takes to fill a prescription, the number of immunizations given, the number of customers signing up for 90-day supplies of medication, to name a few.
The fact that tasks are being tracked is not the problem, pharmacists say, as customers can benefit from services like reminders for flu shots and refills. The issue is that employees are heavily evaluated on hitting targets, they say, including in areas they cannot control.
In Missouri, dozens of pharmacists said in a recent survey by the state board that the focus on metrics was a threat to patient safety and their own job security.
“Metrics put unnecessary pressure on pharmacy staff to fill prescriptions as fast as possible, resulting in errors,” one pharmacist wrote.
Of the nearly 1,000 pharmacists who took the survey, 60% said they “agree” or “strongly agree” that they “feel pressured or intimidated to meet standards or metrics that may interfere with safe patient care.” About 60 percent of respondents worked for retail chains, as opposed to hospitals or independent pharmacies. Surveys in Maryland and Tennessee revealed similar concerns.
The specific goals are not made public, and can vary by store, but internal CVS documents reviewed by The Times show what was expected in some locations last year. Staff members were supposed to persuade 65% of patients picking up prescriptions to sign up for automatic refills, 55% to switch to 90-day supplies from 30-day, and 75% to have the pharmacy contact their doctor with a “proactive refill request” if a prescription was expiring or had no refills.
Pharmacy staff members are also expected to call dozens of patients each day, based on a computer-generated list. They are assessed on the number of patients they reach, and the number who agree to requests.
Representatives from CVS and Walgreens said metrics were meant to provide better patient care, not penalize pharmacists. But dozens of pharmacists described the emphasis on metrics as burdensome, and said they faced backlash for failing to meet the goals or suggesting they were unrealistic or unsafe.
The refill issue
Mark Lopatin, a rheumatologist in Pennsylvania, says he is inundated with refill requests for almost every prescription he writes. At times he prescribes drugs intended only for a brief treatment — a steroid to treat a flare-up of arthritis, for instance.
But within days or weeks, he said, the pharmacy sends a refill request even though the prescription did not call for one. Each time, his office looks at the patient’s chart to confirm the request is warranted. About half are not, he said.
Aside from creating unnecessary work, Lopatin believes, the flood of requests poses a safety issue. “When you are bombarded with refill after refill, it’s easy for things to fall through the cracks, despite your best efforts,” he said.
Pharmacists said many unwanted refill requests were generated by automated systems designed in part to increase sales. Others were the result of phone calls from pharmacists, who said they faced pressure to reach quotas.
The American Psychiatric Association has been hearing from members that CVS was giving patients larger supplies of medication than doctors had directed. While it is common for pharmacies to dispense 90 days’ worth of maintenance medications — to treat chronic conditions like high blood pressure or diabetes — doctors say it is inappropriate for other drugs.
For example, patients with bipolar disorder are often prescribed lithium, potentially lethal if taken in excess. It is common for psychiatrists to start a patient on a low dose or to limit the number of pills dispensed at once, especially if the person is a suicide risk. But increasingly, the psychiatric association has heard from members that smaller quantities specified on prescriptions are being ignored, particularly by CVS, according to Schwartz, the group’s president.
‘The amount of busywork we must do while verifying prescriptions is absolutely dangerous. Mistakes are going to be made and the patients are going to be the ones suffering.’
Pharmacist writing to the Pennsylvania pharmacy board