Ethics at the Chain Pharmacy
When I began medical practice (in the last century), most pharmacies in my area were owned by the pharmacist. I can't even name one now. To replace them, we now have giant corporate entities such as CVS (9,600+ locations), Walgreens (over 8,100) and of course Walmart (4,500). Your local grocery chain likely has a pharmacy. And each of the giants above act as Pharmacy Benefit Managers (PBM) for multiple insurance companies, doling out prescriptions in store or by mail to customers. But only those prescriptions found in the "formulary", which the kindly PBM has decided to provide you.
But you thought the doctor wrote the prescription? Strictly speaking...yes. But effectively the prescription is only filled if it meets formulary requirements. Which can be summed up as: cheap, generic and possibly effective (in that order). If the prescribed medicine isn't formulary, or the use or quantity is out of their guidelines, the patient and doctor must submit to a tortuous process calling "preauthorization" This involves calling a clerk in say, India, and trying to guess what he or she needs to hear to get approval. Now, this is all delaying the receipt of the drug which presumably is needed by the patient. The PBMs call this "cost effective prescribing". I call it an atrocity.
Next time you try to get a service that you have already paid for in advance like health insurance, imagine how that would work using the PBM model. You have a service contract for your new car, but you can't replace a worn tire, because it "shouldn't have worn out yet." Your 20 year warranty roof leaks, but the company has decided replacing barrel tile is too costly, so you can only have asphalt shingles. Even worse, the fire department comes to put out a fire at your home, but they have to call someone in India to get approval, once they use the approved amount of water.
This hassle is frustrating enough to my patients and I, but the behavior of the pharmacy staff is really what astounds me. Now these are licensed professionals, pharmacists and pharmacy techs, and while they work for the mega-corporation, they swear an oath to serve the public. The event that spurred this post today involved my elderly diabetic patient who went in to get his insulin, he was running out. The pharmacist told him he was getting his refill too soon, come back in a few days. No other solution, can't get it earlier. The patient went home, as many seniors do, cowed by the encounter with his "company-man" pharmacist. Fortunately his daughter found out and called me (when he told her his sugar was over 300). I had some words about ethics with the pharmacist, but I could sense an over-the-phone shrug of the shoulder. After all, the PBM would hear that the doctor overrode the limit, not him.
