The Chicago Tribune did a really nice piece of investigative reporting on pharmacies. What thy found is scary but not too surprising as it is hard for retail pharmacies to make money while saying no.
The Tribune reporter walked into an Evanston CVS pharmacy carrying two prescriptions: one for a common antibiotic, the other for a popular anti-cholesterol drug.
Taken alone, these two drugs, clarithromycin and simvastatin, are relatively safe. But taken together they can cause a severe breakdown in muscle tissue and lead to kidney failure and death.
When the reporter tried to fill the prescriptions, the pharmacist should have warned him of the dangers. But that’s not what happened. The two medications were packaged, labeled and sold within minutes, without a word of caution…In the largest and most comprehensive study of its kind, the Tribune tested 255 pharmacies to see how often stores would dispense dangerous drug pairs without warning patients. Fifty-two percent of the pharmacies sold the medications without mentioning the potential interaction, striking evidence of an industrywide failure that places millions of consumers at risk.
Failure rates ranged from 30% to 70% depending on the type of pharmacy. The independent mom and pop stores did the worst.
Some pharmacists who were tested got it right, coming to the counter to issue stern warnings. “You’ll be on the floor. You can’t have the two together,” said one pharmacist at a Walgreens on Chicago’s Northwest Side. Said a Kmart pharmacist in Rockford: “I’ve seen people go to the hospital on this combination.”
But in test after test, other pharmacists dispensed dangerous drug pairs at a fast-food pace, with little attention paid to customers.
I think this is a business model problem as much as a training problem. Most retail pharmacies make their drug counter money on dispensing fees. Each bottle of pills that goes out earns a fee. Each bottle of pills that sits on a shelf does not earn a dispensing fee; instead it costs money to sit on the shelf. Widget based payments lead to an incentive to sell as many widgets as possible as quickly as possible. More realistically, most pharmacies are not the profit centers of the retail store. Instead the profit occurs as the customer with the prescription buys a couple rolls of Lifesavers and a bottle of Moxie tonic on the way out to make the medicine taste less bad.
Specialty pharmacies like a nuclear medicine pharmacy have the incentive to get it right as all that they sell is a limited number of high value doses and nothing else. If they develop a reputation with their expert buyers that they screw things up in ways that hurt patients or cost money, they lose their business. It is a very different business model than retail public facing pharmacies.
It is hard to monetize a reputation of being always right even when being right means saying no a lot and sending the customer back into being a patient and forcing a new interaction cycle with their doctor. Good enough is often good enough. Sure, there is probably a training need identified by this investigation but I think the underlying business model and its incentives would need to be re-examined.