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    Is community pharmacy a dying profession?

    Truman LastingerBy Truman Lastinger, RPh

    Throughout history, occupations have been replaced by new innovations. In the United States, building and assembling wagon wheels was once a way of life for many men. Local sawmills were an everyday part of living. In the South, well diggers were long in demand. Blacksmiths made a good living for generations. In the early to mid-twentieth century, extraction of turpentine from pine trees was a common occupation.

    Nowadays, mule-skinners and ox drivers are no longer with us. Nobody cuts barrel staves any more. Dime stores and general stores are practically a thing of the past. All too often, locally owned hardware stores have been replaced by superstores.

    The payment dead end

    It appears to me that pharmacy is in the process of changing also. Over the past few years, corporate America has taken over our ‘’profession.” No longer does a pharmacist have any say as to what drug he will purchase. Nor does he have time to interact with patients — “customers” — even though he is mandated to do so by OBRA. Now he is under fire when he refuses to fill a narcotic prescription, as he was taught to do.

    And he has no say as to how much the drug he is responsible for costs. He has absolutely no say as to what he will charge for the drug.

    The pharmacist has always provided a service. The problem is that there is no way he can bill for or get paid for this service.

    Originally the price for this service was included in the markup on the drug that was sold or dispensed. In the ’60s, the pharmacy schools and the pharmacy associations promoted a professional fee rather than a markup. They said that a professional fee was necessary for the public and other healthcare professionals to recognize that the pharmacist is also a professional.

    Pharmacists blindly accepted this innovation, and the professional fee became the automatic markup on the drug being dispensed. Because there was no method proposed to account for inflation, we were stuck with a fixed markup. As the price for the drugs in a prescription increased, the only way a pharmacy could stay in business was to cut down on employee payrolls or fill more prescriptions.

    Then third parties took over processing and paying for the prescriptions.

    Third-party takeover

    Today, the drug companies, the insurance companies, and the benefit managers have complete control of the profession of pharmacy.

    For one thing, the drug manufacturers have an interesting control over the FDA. The life of the patent on a drug is extended unduly when the manufacturers change the salt, the dissolving point, and even the shape of the drug, with no real advantage over the original. Then as soon as they can’t get any more mileage out of the patent, they get the FDA to approve the sale over the counter. Apparently these drugs were not dangerous enough for the last 10 years to warrant Rx only.

    The only way I can figure it is by the money involved. When the manufacturers have to supplement the costs of the FDA, they have to have an influence on what the FDA approves.

    16 Comments

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    • Mr. BTaffin
      Interesting that you talk about the dying profession. I wanted to be more clinical and went back to medical school to get my MD degree. I now have a wellness company and medical practice. My wellness company focuses on assisting retail pharmacies to offer clinical screening and drug monitoring programs by partnering with my company Wellspring Medical. The programs provide opportunities for the pharmacists to offer cardiac and pulmonary programs, weight loss programs, and smoking cessation programs, all of which are billable. I wish more pharmacists would take the time to get involved. Some have but I have had pharmacists tell me they don't have the time to work with patients. I tell them the risk of NOT doing these programs will certainly lead to their demise. Pharmacists need to integrate themselves to be more clinic versus technicians.
    • ChrisThompson
      Clearly pharmacists are passionate about the deterioration and degradation of our profession. I come across these types of articles (or long posts on various pharmacy forums across the internet) all the time. There is always someone lamenting the direction our field has taken and continues to take. Understandably. But simply asking the question of whether Community Pharmacy is a dying profession (short, easy answer: Yes) doesn't do any of us any good. This article does a nice job of summing up the various reasons the profession is where it's at (even if a few of the reasons are applicable across the jobs market as a whole in America at the moment) and I think this is important. But, where this, and so many articles like it, fails is when it comes to asking the more important questions: 1. If we can fix it, how? 2. If we can't fix it, where do we go next? I know these are huge questions with very complex answers (and possibly no right answers), but the practice of reviewing the woefulness of the state of pharmacy is essentially just sad-sack navel-gazing. It is nothing more than nostalgia for the good old days. And this type of nostalgia is always dangerous because it means we've stopped considering a viable future. We've stopped pushing for change. We've stopped innovating. Unfortunately we're not lucky enough to have the built-in protection that the medical doctors' community has (from decades of systematically adding safeguards to their proprietorship, responsibility, and legislation). But we can't just look back and wonder what happened. We have to look at those two questions above and really think about how they should be answered. Rather than bore the rest of you with my answers to the questions (that's more suited for an article, not a forum post), I'll point to three medical professions that are taking fundamental steps in improving their professions and ensuring that they will continue to exist in an independent capacity for years to come: Nurse Practitioners, Nurse Anethetists, and Physical Therapists. I point to these professions because, unlike Dentists and Optometrists, these three never had a lock-down on their market. Physicians already existed and completed the functions of Nurse Practitioners and PTs. Anesthesiologists worked without CRNAs for years. But all three of those professions are growing, adding various levels of responsibility to their professions, and becoming increasingly independent; all while Pharmacy wastes away because we can't make up our minds of what we want to be. Those three professions are highly organized, unified, and interested in advancement. Pharmacy is disjointed, at odds about where our focuses should be, and have interests that range from advancement to money to better working conditions. We can't move forward when we're all moving in different directions. Not until we start banding together and looking out for the rest of the profession can we hope to reestablish our autonomy, recapture our independence, and take our profession into the next cycle of its life.
    • ChrisThompson
      Duplicate post deleted
    • TrumanLastinger
      Chris, I am glad you took the time to read the article. Many of us older pharmacists have plenty of reasons to lament the situation. The only way to get attention is to complain and lament. The squeaking wheel gets the grease. You call it sad-sacking and navel gazing. How can the younger generation of pharmacists know that things could be better. If you read closely you will see that I proposed getting the authority to make decisions in regards to our "patients". only then can we be a true profession. If we can act with unity we might be able to turn things around but I have watched over the years and find that most pharmacists are primarily interested in doing a good job and do not consider the overall picture. Thanks for your comments Truman
    • RobertDeBus
      I am an old retired 4 y grad RPh; some items mentioned here were "issues" why back then; now only more so. Most of us were expected to have our own store (pharmacy) within 10-15 years. Nowdays one with this idea should be in a mental institution. Chains and big box stores have taken over the "profession" - just another "profit (or cost)" enter. Service to the patient is not expected. Back then we had "drug stores" then we had Pharmacies . in one humble view we have Drug Stores again - pharmacy is incindental. Yet, the actual profession is much advanced in what a REAL Pharmacist could / should do -just check a modern hospital. Its sad. 3rd parties control all "retail" pharmacy. Bob
    • Anonymous
      I have worked as a pharmacist for one of the "big 3" retail chains for the last 20 years and at one point in my career I could have seen myself staying until retirement. However, I never thought I would see our working conditions deteriorate to the point they are now. Like so many of my fellow pharmacists here that have already left or are on the lookout for other jobs, there is a rapidly growing level of discontent among both pharmacists and technicians. In a continual attempt to artificially inflate our stock value, the company has cut our staffing levels to an all time low, to the point where I am often checking prescriptions that were due several days ago. I spend the vast majority of my shifts apologizing to customers, most of which have made more than one trip to the store, only to find that their prescriptions are not ready. Numerous customers have told me they have complained to both our corporate and district offices about the ridiculous understaffing and lack of service provided, they all say nothing ever changes. It's as if our company does not even care that we are so understaffed we can not possibly provide any level of customer service to these people. From a consumer perspective, our service is so poor, I personally would never get my family's prescriptions filled there, and am amazed that people ever come back. I can only surmise those who return are locked in due to their insurance. Although our stock is at its highest level ever, I have been steadily selling mine off in anticipation of the understaffing repercussions will likely come back to haunt those above. Not too long ago, my company tried to sneak a legal document in under the guise of a training module, with all the critical details appearing on the last page of a multi-page document, where they disclose you will be signing away all of your legal rights to ever sue them, and that you agree to use their "arbitration process" to solve any conflicts. Icing on the cake. I think as pharmacists we have missed the band wagon too. we should have been smart and fought for a union to protect us from the horrific working conditions they throw many of us into. We are hourly when they want us to be and then we are salary when they want us to be. What they really want is free labor period. My last 2 raises were the lowest ever, about the same dollar amount of my increase after my 1st year of work, 20 years ago. The worst part is not the money, it's the working conditions, the danger our customers are place in every day due to the total understaffing of the pharmacy.
    • TrumanLastinger
      I agree with most of what you have discussed. When we get to the possibility of unionizing I have to believe that this would only protect the status quo for period of time. Consider what has happened to the railroad unions, the automotive unions. and most manufacturing unions. They have been on the decline for some time and these people are being replaced by computers and robots. Unionizing still does not allow us to have any control over what we are doing It can only give better working conditions but for how long. I don't think it could possibly improve the staffing level to a point that we would be comfortable with. Truman Lastinger
    • TrumanLastinger
      I agree with most of what you have discussed. When we get to the possibility of unionizing I have to believe that this would only protect the status quo for period of time. Consider what has happened to the railroad unions, the automotive unions. and most manufacturing unions. They have been on the decline for some time and these people are being replaced by computers and robots. Unionizing still does not allow us to have any control over what we are doing It can only give better working conditions but for how long. I don't think it could possibly improve the staffing level to a point that we would be comfortable with. Truman Lastinger
    • Anonymous
      Nice summary, Truman. Some of the problems of Pharmacy could actually be solved by the Chains. Others must be solved by the practitioner. I think everyone understands that US Pharmacy is dominated by three chains --CVS, Walgreens, and Rite-Aid. These chains are functionally a cartel, ie., they are so enormous that nothing done by one chain can possibly surprise the others. If they knew each others' moves in advance, that would not be too surprising. Functionally, the 3 chains are no different from a monopoly. Since we already know that anti-trust activity no longer happens in the US, these 3 big chains could all independently decide, effective with the new contract renewals, to write additional billing into their contracts as follows; Fees required for counseling, fees required for MTM, fees required for printed copies of the leaflet. If a customer does not want to pay the fee, they have the right to refuse the counseling/leaflet/etc. These fees would be allowed by contract, set by the pharmacy, collected directly from the patient, and independent of reimbursement for filling the prescriptions. Insurance is likely to go along with these arrangements if it means that they risk being shut out of the big 3 for a year. Such changes would not affect their bottom line, only that of the pharmacies. Once instituted, we would be doing a lot less counseling, but the counseling we do would be more needed by those willing to pay. Pharmacies could sell patients a yearly unlimited counseling package, or charge them a-la-carte, per patient wishes. As for the independents, we need to have a good hard think about how labor unions got the right to strike, assemble, and plan. At their beginning, it was illegal to join a labor union, illegal to strike or walk off the job--you name it, the whole thing was illegal. But they did it anyway because the working conditions were so terrible, and (in the case of the food industry) corporations were endangering the public health. If you don't know this, read "The Jungle" by Upton Sinclair. Eventually the laws were changed to accomodate the unions. Independents need to band together and demand equality in contracts and wholesale pricing to the chains, and they need to blacklist insurances and wholesalers that do not meet their requirements. Legal or not, they need to do it anyway, preferrably in conjunction with actions by the Chains along those lines. Laws will eventually be changed to accomodate these actions. Why? Because Pharmacy has already reached the place at which we are endangering the public every day with mail-order, inhuman working conditions and short staffing, to name a few. Individual pharmacists are blamed when something goes wrong, but they have no control over their working conditions. If the corporations cannot find a way to improve these conditions, lawyers will eventually find a way to help them. Finally Truman, let's remember something that happened in Pharmacy in the 1990's that gives us a little hope for the future. Back then, albuterol nebulizer solutions went off patent, and someone figured out that they could buy equipment to compound the nebs at the pharmacy level, sell them when a neb prescription came in and make a larger profit, even though the cost to the consumer was sometimes halved. It is a long story, but locally-brewed nebs did not stop until the PMA manufacturers dropped the price of their nebs by about 75% to be competitive with what was being done at the local pharmacy. For a brief, shining moment competition returned to that tiny corner of the Pharmacy marketplace. The public benefitted, the local pharmacy benefitted, and the lack of competition at higher levels was exposed. All these things need to happen on a wider scale. If the playing field is leveled, if competition returns, if we get organized to demand our rights, then pharmacy can be saved. If not, it will go away.
    • TrumanLastinger
      Thank you for your comments. Many of your suggestion are valid and could help pharmacy. I don't agree with the unionization however. Look what happened to the railroads and the auto industry.
    • Anonymous
      Truman, in addition to all the points you make, consider the possibility that big pharma may one day surpass PBM's with their own automated, direct mail order to the consumer. Possibly from offshore fulfillment centers, if they can effect buy-in from the FDA. Then there are the advancements in computer science. What if IBM's Watson were applied to designing drug therapy? For a small fee, Watson will evaluate all of a patient's data, design a drug regimen for optimum outcome, and forward the prescriptions (with the physician's electronic signature, of course) to the appropriate fulfillment center for next day delivery to their home. What's more, for a small fee, Watson could also review changes in their health from that smart band on their wrist and contact their physician with appropriate alternatives to current therapy. Naturally, somewhere in a cubicle, there will be a pharmacist to answer any questions patients might have, in between remotely verifying the accuracy of a robot that never makes mistakes, at a fulfillment center in India or China (that is until our American colleges of pharmacy team with foreign pharmacy schools, for a fee, to train their graduates and help them get U.S. licensesure). After seeing all the changes in the last 30 years of my practice, I don't believe that these scenarios are that far-fetched. And, Truman, you might be wrong. Perhaps being a cooper that makes oak barrels for premium American Bourbon will be a far more lucrative trade than pharmacy in the next 30 years.
    • TrumanLastinger
      Wow, Thanks for the comments. I would also hate to see this coming to pharmacy.
    • TrumanLastinger
      Wow, Thanks for the comments. I would also hate to see this coming to pharmacy.
    • Anonymous
      Pharmacists are getting exactly what they deserve. For decades we have been acting like sheep rather than the wolves we should have been in order to survive. The short sightedness we have shown over the years has been unbelievable. Independent pharmacy owners accept drug plans that actually cost them money in order not to lose business. Other pharmacists work for chain stores, and agree to work under conditions that were deemed unacceptable in the early 1900's. Guess what my fellow pharmacists, it still takes a pharmacist to run a pharmacy. We hold the trump card! We must come together and put an end to this madness. For once show some balls.
    • Dr. MCrown
      Just got a great laugh from the advice to "For once show some balls" from an ANONYMOUS post! haha! The bottom line, corporations run our country, from healthcare to food and everything in between. Until we Pharmacists have an organization with billions of $$ to push our agenda, good luck and enjoy the ride. My best advice, which I am following, work less, learn to grow your own food and don't be held hostage by corporate America!
    • TrumanLastinger
      Thanks I hope there is still time and wonder if the pharmacists will be able to do something good.