Chaos in pharmacy reimbursement leads to patient safety issues, and enough is enough

News broke last week that the Oklahoma State Board of Pharmacy (OSBP) had fined four CVS pharmacies in the state for poor staffing and medication errors. This is a positive development for both the well-being of pharmacists and technicians and the prioritization of patient safety.

But it’s going to take much more than a fine to keep patients safe.

The actual sum of the fine—$125,000—is a drop in the bucket for a massive conglomerate like CVS Health. What’s significant is that the OSBP sanction validates the outcry of pharmacists and technicians that understaffing, lack of breaks, and volume metrics make medication errors more likely to occur.

Raised awareness, however, is far from the solution to the problem. We need a total restructuring of pharmacy payment mechanisms.

  • Patient care in pharmacies needs to become profitable. This is why we fight for reimbursement of pharmacist-provided patient care services under Medicare Part B, or what’s popularly known as provider status. Chains are not evil—in fact, they serve patients and employ pharmacists. Having said that, they are businesses, and they exist to make money. If pharmacists get paid for patient care, chains (and all pharmacies) would change their business model to take advantage of that. Our pharmacists in high-volume chains crave the ability to use their education and not just count, pour, lick, and stick. We are the second-highest educated professionals in health care, behind physicians. Every pharmacist who’s graduated since 1999 is a Doctor of Pharmacy, and our veteran pharmacists who graduated before that have decades of experience that empower them to care for patients.

    You can be a part of these efforts in payment reform. Visit APhA's advocacy page and tell Congress to include provider status in the next package of coronavirus legislation. Pharmacists must be included in COVID-19 testing and immunization efforts if we are to get this pandemic under control.

    Making your voice heard through grassroots advocacy is a vote for yourself. You can help patients get healthy and stay healthy. You can help communities avoid preventable illnesses and provide education on managing chronic diseases. You can enhance public and even global health. Tell Congress that you should be paid to do these things. Campaign for yourself, your patients, and your profession.
  • PBMs must be tamed and held accountable. PBMs reimburse some pharmacies less than others, often reimbursement is so low that pharmacies lose money on prescriptions, go under water, and drown. This leads to pharmacy deserts and patients losing access to care. Furthermore, they impose DIR fees to retroactively steal money from pharmacies for amorphous “quality standards,” which largely comprise factors over which pharmacies have zero control. PBMs must be stopped from using abusive payment practices to starve pharmacies and rob patients of the accessible, reliable care that pharmacists provide. Before coming to APhA, I was chief pharmacy officer at Cleveland Clinic, and I know that there have been 300 net community pharmacy closures over the last 3 years in Ohio alone. We need transparency and an end to unchecked PBM greed. If we don’t reverse the trend of widespread community pharmacy closures due to PBM shenanigans and inadequate reimbursement, our community pharmacies will become extinct in 5 years.
  • Vertical mergers must be policed to ensure they actually benefit patients and the public. We were disappointed by recently issued U.S. Department of Justice/Federal Trade Commission guidelines that promised little to inspire confidence that they would appropriately scrutinize the mergers that give massive corporations control over all levels of the pharmacy supply chain. Vertical mergers are anticompetitive and give entities united as one disproportionate power in the health care marketplace. PBMs are already vampiric to the pharmacy industry, most obviously independent pharmacy. Now PBMs have their own pharmacies and have even integrated with insurers in some cases. There’s nothing that proves that such arrangements will benefit the public in any way.

The last thing that pharmacists want to do is harm a patient. They go to school to improve the health of society. But misaligned incentives have turned pharmacies into factories.

How much is enough? What will it take before we finally pass legislation to grant provider status to pharmacists so they can get paid to improve public health as opposed to go faster on the prescription-filling treadmill?

We know that chaotic reimbursement models put patients at risk. In 2016, Sam Roe, Ray Long, and Karisa King at the Chicago Tribune first publicly exposed the dark underbelly of the impact of the current pharmacy reimbursement model in their groundbreaking article, “Pharmacies Miss Half of Dangerous Drug Combinations.” The reporters used “secret shoppers” to demonstrate that a significant number of potentially deadly drug combinations were filled without the overburdened pharmacist catching the error and discussing it with the patient. Illinois implemented some reforms, and some chains attempted technological improvements after the bombshell story. But we know these were a band-aid at best.

Next came New York Times reporter Ellen Gabler’s January 31 story, “How Chaos at Chain Pharmacies is Putting Patients at Risk.” Gabler further exposed the patient safety issues around high-volume pharmacies and the torment of pharmacist and technicians terrified they’d eventually harm a patient. Gabler followed that with another story of buried medication errors at a chain pharmacy on February 21.

Chains aren’t to blame, and our sisters and brothers working in chains are overworked and underappreciated patriots serving society. The cause of our upside-down priorities is how our health care system pays for prescription drugs and patient care. CVS pharmacists as well as their peers in other high-volume chains are giving 150% every day. That’s especially noticeable during the pandemic, as pharmacy staff put themselves at risk every day to ensure patients get the care they need.

They deserve to be compensated for delivering care, not dispensing drugs. APhA salutes OSBP for taking a stand against volume-over-value, profits-over-patients business practices—and we’ll keep fighting for provider status until we win.