The Pharmacist Advocate – Happenings in a Global Pharmacy on its way to you!

Editor’s Note: In March 2016 i2P published an article by Peter Sayers regarding the globalisation of Australian community pharmacies (read ).
We also published well before the last election that Medicare privatisation issues would became the focus of that election and that the election would be basically fought on health.
Future elections are likely to keep health as a central issue simply because our health system is not coping, and one of the reasons for that is that pharmacy is being held back from the management of primary health care.
Until that issue is adjusted so that pharmacy has a genuine central management role, well supported politically and financially, primary health care will remain expensive and cumbersome.

Medicare is obviously valued by the Australian population so any political party that would look to disrupt this central health service would do so at their peril.
In our recent articles on what to expect when a global invasion of pharmacy conglomerates invaded Australia occurred we provided information on their entry strategies, and indeed highlighted that the Boots-Alliance group were already active in preliminaries to increase brand awareness and lining up potential partners to facilitate their entry (such as Sigma wholesalers).

The article that follows gives a description of some of the activities of the CVS group of pharmacies in the US, and how they are essentially destroying the spirit of their pharmacist employees and not creating appropriate patient care policies.
Also the disparity when legal penalties are applied to the company compared to that of its employed pharmacists.
Daniel reserves special comment for Caremark, a patient benefit management company (owned by CVS) that would be a privatised version of Medicare should CVS hit Australian shores.
Conflict of interest is evidently a severe problem within Caremark.

Daniel Hussar is a pharmacist academic who publishes a newsletter titled The Pharmacist’s Advocate.
He is passionate about his chosen profession of pharmacy and speaks out fearlessly when something needs to be said.
He is often called as an expert witness in legal cases involving pharmacies, pharmacists and patient damage.
i2P is re-publishing his current newsletter article because it has relevance to Australian pharmacy and it should be filed for future reference or kept ready to brief our politicians as to what they may be voting for, as future pharmacy and health issues arise.
Australia must preserve what is right about its health system and pharmacy has always been a central player providing open access to quality information and advice.

CVS has an Exceptional Opportunity but Rejects It – To the Peril of its Customers and Frustration and Risk of its Pharmacists!

There is probably no other organization in American pharmacy that can match CVS with respect to the opportunity for having a strongly positive impact on the practice of pharmacy.
It has approximately 10,000 pharmacies and extensive financial resources. It has thousands of highly capable pharmacists.
Its leadership deserves credit for certain of the decisions that have been responsible for its growth and financial success.
It has received accolades for its excellent decision to discontinue the sale of tobacco products.

But then I am pulled back to reality by headlines such as the following that appeared in the June 30th issue of The Boston Globe (Vivian Wang):
“CVS pays $3.5m to settle claims it filled fake painkiller prescriptions”

The story reports on allegations by DEA investigators that pharmacists in 50 CVS stores in Massachusetts and New Hampshire dispensed forged prescriptions more than 500 times.
CVS responded by agreeing to settle the claims for $3.5m and to improve training of employees to recognize forged prescriptions.
It said that it settled the allegations to avoid the cost and inconvenience of further legal proceedings.

Apparently $3.5m buys the conclusion of the investigation, but many questions remain such as the following: Are the pharmacists about whom the allegations were made still employed at CVS?
If so, did they receive any disciplinary action?
Have any of the alleged actions been reported to the State Board of Pharmacy?
If so, did the Board take disciplinary action?

If it was an owner of an independent pharmacy against whom such allegations were made, it could be anticipated that her/his pharmacist license might be suspended and that the subsequent ramifications might necessitate sale or closure of the pharmacy.
There is a gross inequity with respect to the consequences that an owner of an independent pharmacy might experience when compared with those of a chain pharmacist and her/his company.

This inequity can be defined by the number of dollars it takes to settle the allegations.

I wish to be clear that I deplore every situation in which a pharmacist betrays the public and our profession by dispensing prescriptions that he/she knows or strongly suspects are forged.
However, to what extent does a company’s policies, culture, and work environment contribute to situations in which pharmacists make bad decisions?
Related questions include: When a prescription is received, is there a specific period of time in which a pharmacist is expected to complete and dispense it?
What are CVS’s expectations (quotas) regarding the number of prescriptions that must be dispensed before additional staffing (pharmacists and/or technicians) is provided?
Is the number of prescriptions dispensed a factor in the determination of bonuses for pharmacists?
What are CVS’s policies and procedures with respect to how its pharmacists should respond when they suspect a prescription is forged?
For example, should the prescriber identified on the prescription be contacted to confirm that it is valid?
Should the police be contacted when it is known that a prescription is forged?
When a pharmacist declines to dispense a prescription, do the policies and procedures keep the potential for retaliation at the lowest level possible?

There is no reason to think that these questions were even considered by the DEA and/or other investigators.
Reaching the settlement was apparently based only on dollars.
I raise these questions because I consider them very important, and not to make excuses for bad decisions of pharmacists.

Pharmacists must give the highest priority to their responsibilities to their patients and to the laws and ethics of our profession, and must not use company policies and/or pressure as an excuse for compromise or inappropriate actions.
It is noteworthy that a CVS pharmacist with a physician who is CVS’s medical director have published an article in the New England Journal of Medicine (August 21, 2013) titled, “Abusive Prescribing of Controlled Substances – A Pharmacy Review.” However, to my knowledge, CVS has been silent about the problems that have been identified in its own pharmacies.
A title for such an article might be, “Abusive Dispensing of Controlled Substances – The CVS Experience.”

Very regrettably, the situation identified above and as described in The Boston Globe is not an isolated experience.
There are frequent reports in the news regarding errors, as well as problems pertaining to controlled substances involving CVS stores.
These situations are almost always settled and I have heard the CVS standard response so often that I can anticipate it before they say it –
We acknowledge no wrongdoing. We are settling the matter to avoid the cost and inconvenience of further legal proceedings. The safety of our customers is our highest priority.

In the situations in which I am aware of some of the specifics, the truth is that there was wrongdoing, and customer safety did not have priority.
In addition to the many allegations of the DEA and other regulatory agencies, numerous lawsuits are filed against CVS, as well as other large chain and mail-order pharmacies, because patients have been harmed or died as a consequence of alleged dispensing errors, preventable adverse events and drug interactions, negligence, or other mistakes. Check here to know the process for sealing a criminal record, by expert lawyers.
I am sometimes contacted by attorneys involved in such litigation who request that I serve as a consultant and/or expert witness.

Although the total number of lawsuits about which I have been consulted is relatively small, a number of them have involved CVS.
In some of these situations, it has been my opinion that there is not sufficient basis for a lawsuit and I decline to participate further.
In some other situations, I have worked with the attorneys who are defending CVS and its pharmacists.
In a few situations in which patients have died or experienced severe harm, I have worked with the attorneys for the plaintiffs or their families who are suing CVS.
I much prefer to not participate as an expert for plaintiffs in actions against pharmacists/pharmacies.
However, when
1) it is absolutely clear to me that an error has been made and/or there has been serious negligence, and
2) the defendant pharmacy denies any wrongdoing or claims that its pharmacists have no responsibility to do anything other than dispense a prescription exactly as the prescriber has written it, I have agreed to work with the plaintiff’s attorneys.

The cases in which I have participated as a plaintiff’s expert against CVS have involved deaths or serious/disabling, irreversible adverse events.
In most lawsuits filed against pharmacies, very few people ever hear about tragedies that have occurred because these cases rarely go to trial where the news media would become aware of and publicize the circumstances.
Rather, these lawsuits are almost always settled out of court and the terms of the settlement are classified as confidential.
As just one of the individuals who is contacted, I am aware of the specifics of a relatively small number of the lawsuits against CVS.
However, it is my understanding that, at any given time, there is a very large number of active lawsuits against CVS.

That this observation is accurate is essentially confirmed by CVS’s refusal to identify the number and type of lawsuits it is defending.
This information will remain secretive until some attorney identifies a strategy to obtain it, a whistleblower provides it, or a court or state board of pharmacy is sufficiently concerned to force CVS to reveal it.

What should CVS do?

I have the following recommendations for CVS:
1. Get rid of Caremark! In my opinion, it is a blatant conflict of interest for a corporation to own a pharmacy benefit manager/administrator (PBM) and a large chain of pharmacies, and the Federal Trade Commission should never have approved the acquisition of Caremark by CVS.
Caremark’s inequitable and anticompetitive terms, policies, procedures, and audits are strongly and almost universally criticized by pharmacies other than CVS pharmacies.
Concerns about direct and indirect remuneration (DIR) fees imposed by PBMs on pharmacies are the subject of a recent communication from the National Community Pharmacists Association (NCPA). For some pharmacies these fees can total thousands of dollars each month, and pharmacists responding to a survey identify CVS Caremark and Aetna as being the most egregious in this area.

For Caremark to be able to provide incentives to use its mail-order pharmacy to patients enrolled in the prescription plans it administers is anticompetitive.
It is ironic that, in 2004, the CEO of CVS at that time stated, “We are opposed to forcing patients to use a mail order service and then dictating which mail order pharmacy to use.”

2. Walk your talk and actually give a high priority to patient safety! CVS’s hypocrisy with respect to its stated concern for patient safety is not acceptable.
It is my understanding that the number of errors of commission and omission that occur in CVS pharmacies is astounding.
Most of these errors are never known to anyone outside of CVS.
However, as noted earlier, some have resulted in deaths and serious, irreversible harm.

3. Value your pharmacists!
CVS is fortunate in that it employs thousands of highly capable pharmacists. However, a large number of these pharmacists feel they are important to management only because of the license they hold and not because they are skilled professionals who could provide comprehensive services for patients and make recommendations that would improve employee morale and contribute to the success of the company.
Many CVS pharmacists have strong concerns about their work schedules and what are often very long days in an understaffed and stressful environment in which they are expected to simultaneously manage lines of patients with prescriptions, telephone calls, the drive-through window, and requests for immunizations.
The result is that pharmacists become disillusioned, demoralized, resentful, and burned out.
They feel trapped by company policies and metrics.
This situation is a recipe for errors, and errors occur.

There are statistics but they are known only to CVS, and CVS will not reveal them. However, statistics and evidence of errors are not needed because sound judgment dictates that there is an increased risk of error in an understaffed and stressful workplace in which pharmacists have so little time to commit to each prescription and to speak with patients.
As noted earlier, when serious errors occur CVS will have enough money (sometimes in the millions) to reach a settlement.
However, the pharmacist involved in the error can be at risk of having her/his license suspended or revoked.

How should CVS pharmacists respond?
Many leave and  find another position but this is increasingly difficult to do at a time in which the supply of pharmacists exceeds the number of positions available in many parts of the country.

If employment conditions do not significantly improve, I anticipate that CVS pharmacists will form a national union or related organization that will include both the pharmacist store managers and staff pharmacists.

4. A pharmacist should personally speak with every patient with a prescription!
The “sign here” charade must be abandoned.

5. Other pharmacies/pharmacists should be viewed as colleagues with mutual interests rather than competitors! CVS is intensively competitive, as are other large chains such as Walgreens and Rite Aid.
In communities where these chains coexist, they are in very close proximity to each other, often just across the street or within the same block.
I am aware of a situation in a mid-size community in Pennsylvania in which a CVS and Walgreens were essentially right next to each other and both were open 24 hours a day.
However, no other CVS, Walgreens, or other pharmacy for miles around is open 24 hours a day. CVS and Walgreens give higher priority to competing with each other rather than serving the needs and interests of the community.

In my community, CVS opened a pharmacy directly across the street from an independent pharmacy that had been in that location for decades.
Five recommendations are enough for now. I expect that the upper management of CVS will not agree with many or all of my observations.
If that is the response, I offer to conduct a survey in which CVS pharmacists can respond anonymously to determine the extent to which they consider my comments to be valid.

CVS has an exceptional opportunity!

At the present time it is not respected by many within the profession and by many even within its own company.
However, it could regain the respect and positive reputation it enjoyed when the company started.
At that time it promoted the professional role of the pharmacist and provided their pharmacists with the time to speak with patients and provide comprehensive professional services.

I am available to help as an unpaid consultant.

…………..Daniel A. Hussar

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