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    Monday, January 03, 2005

    Requiem for the Drugstore: This year, more insurance plans are insisting that their enrollees get their drugs by mail, which may well mean the end of the local drug store:

    Across the country, many state and city governments, as well as private employers, already require employees to obtain their medications for chronic conditions through the mail. Early last year, General Motors, Ford, DaimlerChrysler and the United Automobile Workers introduced a mandatory mail-order requirement, which now applies to more than two million auto industry workers and retirees.

    As drug costs continue to rise, the changeover is accelerating. The switch has already been met with resistance from some consumers who complain that they are losing the help of a knowledgeable, trusted friend - their local pharmacist. For independent pharmacists who depend on walk-in business, the shift to mail-order prescriptions can be devastating.

    "It's going to kill the little guys," said Howard Baskind, owner of Prospect Gardens Pharmacy in the Park Slope section of Brooklyn.

    The biggest drawback to those mail-order plans is the loss of a pharmacist. There's the potential confusion when the mail-order pharmacy changes the brand they use and a pill of a different color shows up in the mail. The patient has no one to go to in that situation to ask if the medicine is the correct one, they just have to take it on faith. Yes, they could call the mail-order pharmacy, but many people have difficulty describing the changes over the phone, and it's also very difficult to get through to someone who understands your questions at the mail order firms. (I've had trouble with that even when I'm returning a call from them - no one ever seems to know who called or why they wanted me and I get put on hold for fifteen minutes or more.)

    The local pharmacy is a far better mechanism for error avoidance. If there's a question about the medication, the patient can take pills in and show them to a knowledgable pharmacist. There's also something to be said for dispensing pills in small quantities (thirty at a time) to a smaller number of people whose drug histories are known by the pharmacist vs. mass automated dispensing.

    UPDATE: Readers are less fond of local pharmacies. From the Precision Blogger:

    I have long argued that the heavyweights in the music industry no longer have any right to exist, and are using their government contacts, and any handy laws, to try to keep a monopoly on a business that no longer needs them to choose artists, mass produce, advertise or distribute.

    I think it is only fair to subject pharmacy stores to the same level of examination. In today's world do they provide services that need to be preserved?

    It seems obvious that the answer is "Yes." You discussed how the pharmacist is the last line of defense against getting a wrong medication. It's obvious there are a set of related issues,
    all of which point to the value of providing human beings who can give objective advice on many aspects of medication.

    Something is seriously wrong however. Pharmacies these days seem to have diversified immensely. They cannot compete with Walmart but they seem to feel that they can only make enough money by being a super convenience store as well. If I remmember correctry, pharmacies were almost as diversified in the 1950's, although their non-pharmacological stock was smaller:

    icecream/soda fountains
    beauty products
    books and mags
    and so on and so on.

    Lack of access to pharmacists will result in tragedies, and more lawsuits against drug companies and employers. So it seems that government and big business should have a serious interest in keeping pharmacists in business. But perhaps their business of the future needs to be something drastically different from what it is now.

    For discussion purposes, here's a strawman: A future pharmacy might receive the drugs that we now propose to send to people via email, and disburse them to customers. Pharmacists would not make a profit on the pills (and would not operate a convenience store). They would be on salary and stipend, and would get bonuses by averting prescription mistakes. These pharmacists would be in a position to give objective advice about remedies in general since they did not sell them at a profit. And they would have the direct contact with patients to at least try to check about conflicting medications, or note when patients had become too hazy to control prescribed self-medication. They would of course stock the medicines that need to be prescribed rapdily and cannot wait for mail. (I'd much rather the pharmacists had these stocks than the prescribing doctors.)

    If you feel it makes sense for pharmacies to sell all the other things they sell, try to imagine a doctors' office that operates a store on the same scale as CVS, on the theory that they expect people to wait 30 minutes to see a doctor, and meanwhile they ought to BUY something.

    And another:

    I agree with a lot of the comment in the NYT article, but the writer seemed (to me) to gloss over the fact that when mail order is "mandatory" it's almost always for chronic conditions and only for chronic conditions - meaning prescriptions where it makes sense to fill a 60 to 90 days supply. Yeah, the article uses the word "chronic" a couple of times, but without specifying what that might mean. So I think it leaves the impression that everyone must get all their prescriptions thru the mail - and I don't think that's true.

    About local pharmacies? First, I live in Manhattan, and I don't have a local pharmacy I really trust. When I was in other cities, I did. Second, if a local pharmacy can compete, good. If not, is there really a problem?   I don't see the logic of paying more for my prescription, so an uncompetitive business can keep charging me more, especialy where I receive no other service in return (e,g, trusted advice). Maybe it's just me, but I don't see the logic.

    It's true that the chain pharmacies have declined in customer service over the years as they focused more on the store and less on the pharmacy. They also stretch their pharmacists rather thin, relying on pharmacy technicians to pick up the slack. I'm not sure what kind of training a pharmacy technician receives, but I know they can never take my verbal orders when I call in a perscription, so their knowledge of drugs must be minimal. The big chains have, in some ways, undermined the expectation of service that used to be associated with a pharmacy.

    It must be sad to be a pharmacist and see your profession decline to nothing more than pill-counters in the eyes of the public.


    posted by Sydney on 1/03/2005 08:31:00 AM 0 comments


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