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| SUBJECT | Subject: [Hangout - NYLXS] Pharm Economcis and Chains killing pts (NY Times)
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Subject: [Hangout - NYLXS] Pharm Economcis and Chains killing pts (NY Times)
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By Ellen Gabler
Jan. 31, 2020
For Alyssa Watrous, the medication mix-up meant a pounding headache,
nausea and dizziness. In September, Ms. Watrous, a 17-year-old from
Connecticut, was about to take another asthma pill when she realized
CVS had mistakenly given her blood pressure medication intended
for someone else.
Edward Walker, 38, landed in an emergency room, his eyes swollen
and burning after he put drops in them for five days in November
2018 to treat a mild irritation. A Walgreens in Illinois had
accidentally supplied him with ear drops ? not eye drops.
For Mary Scheuerman, 85, the error was discovered only when she
was dying in a Florida hospital in December 2018. A Publix pharmacy
had dispensed a powerful chemotherapy drug instead of the antidepressant
her doctor had prescribed. She died about two weeks later.
The people least surprised by such mistakes are pharmacists working
in some of the nation?s biggest retail chains.
In letters to state regulatory boards and in interviews with The
New York Times, many pharmacists at companies like CVS, Rite Aid
and Walgreens described understaffed and chaotic workplaces where
they said it had become difficult to perform their jobs safely,
putting the public at risk of medication errors.
They struggle to fill prescriptions, give flu shots, tend the
drive-through, answer phones, work the register, counsel patients
and call doctors and insurance companies, they said ? all the while
racing to meet corporate performance metrics that they characterized
as unreasonable and unsafe in an industry squeezed to do more with
less.
?I am a danger to the public working for CVS,? one pharmacist wrote
in an anonymous letter to the Texas State Board of Pharmacy in
April.
?The amount of busywork we must do while verifying prescriptions
is absolutely dangerous,? another wrote to the Pennsylvania board
in February. ?Mistakes are going to be made and the patients are
going to be the ones suffering.?
[Read how you can protect yourself against medication errors.]
State boards and associations in at least two dozen states have
heard from distraught pharmacists, interviews and records show,
while some doctors complain that pharmacies bombard them with
requests for refills that patients have not asked for and should
not receive. Such refills are closely tracked by pharmacy chains
and can factor into employee bonuses.
Michael Jackson, chief executive of the Florida Pharmacy Association,
said the number of complaints from members related to staffing cuts
and worries about patient safety had become ?overwhelming? in the
past year. ImageCVS Health ranks eighth on the Fortune 500 list
and has nearly 10,000 pharmacies across the United States. CVS
Health ranks eighth on the Fortune 500 list and has nearly 10,000
pharmacies across the United States.Credit...Jeenah Moon for The
New York Times
The American Psychiatric Association is particularly concerned
about CVS, America?s eighth-largest company, which it says routinely
ignores doctors? explicit instructions to dispense limited amounts
of medication to mental health patients. The pharmacy?s practice
of providing three-month supplies may inadvertently lead more
patients to attempt suicide by overdosing, the association said.
?Clearly it is financially in their best interest to dispense as
many pills as they can get paid for,? said Dr. Bruce Schwartz, a
psychiatrist in New York and the group?s president.
A spokesman for CVS said it had created a system to address the
issue, but Dr. Schwartz said complaints persisted.
Regulating the chains ? five rank among the nation?s 100 largest
companies ? has proved difficult for state pharmacy boards, which
oversee the industry but sometimes allow company representatives
to hold seats. Florida?s nine-member board, for instance, includes
a lawyer for CVS and a director of pharmacy affairs at Walgreens.
Aside from creating potential conflicts of interest, the industry
presence can stifle complaints. ?We are afraid to speak up and lose
our jobs,? one pharmacist wrote anonymously last year in response
to a survey by the Missouri Board of Pharmacy. ?PLEASE HELP."
Officials from several state boards told The Times they had limited
authority to dictate how companies ran their businesses. Efforts
by legislatures in California and elsewhere have been unsuccessful
in substantially changing how pharmacies operate.
A majority of state boards do not require pharmacies to report
errors, let alone conduct thorough investigations when they occur.
Most investigations focus on pharmacists, not the conditions in
their workplaces.
In public meetings, boards in at least two states have instructed
pharmacists to quit or speak up if they believe conditions are
unsafe. But pharmacists said they feared retaliation, knowing they
could easily be replaced.
The industry has been squeezed amid declining drug reimbursement
rates and cost pressures from administrators of prescription drug
plans. Consolidation, meanwhile, has left only a few major players.
About 70 percent of prescriptions nationwide are dispensed by chain
drugstores, supermarkets or retailers like Walmart, according to
a 2019 Drug Channels Institute report.
CVS garners a quarter of the country?s total prescription revenue
and dispenses more than a billion prescriptions a year. Walgreens
captures almost 20 percent. Walmart, Kroger and Rite Aid fall next
in line among brick-and-mortar stores.
In statements, the pharmacy chains said patient safety was of utmost
concern, with staffing carefully set to ensure accurate dispensing.
Investment in technology such as e-prescribing has increased safety
and efficiency, the companies said. They denied that pharmacists
were under extreme pressure or faced reprisals.
?When a pharmacist has a legitimate concern about working conditions,
we make every effort to address that concern in good faith,? CVS
said in a statement. Walgreens cited its confidential employee
hotline and said it made ?clear to all pharmacists that they should
never work beyond what they believe is advisable.?
Errors, the companies said, were regrettable but rare; they declined
to provide data about mistakes.
The National Association of Chain Drug Stores, a trade group, said
that ?pharmacies consider even one prescription error to be one
too many? and ?seek continuous improvement.? The organization said
it was wrong to ?assume cause-effect relationships? between errors
and pharmacists? workload.
The specifics and severity of errors are nearly impossible to tally.
Aside from lax reporting requirements, many mistakes never become
public because companies settle with victims or their families,
often requiring a confidentiality agreement. A CVS form for staff
members to report errors asks whether the patient is a ?media
threat,? according to a photo provided to The Times. CVS said in
a statement it would not provide details on what it called its
?escalation process.?
The last comprehensive study of medication errors was over a decade
ago: The Institute of Medicine estimated in 2006 that such mistakes
harmed at least 1.5 million Americans each year.
Jonathan Lewis said he waited on hold with CVS for 40 minutes last
summer, after discovering his antidepressant prescription had been
refilled with another drug.
Mr. Lewis, 47, suspected something was wrong when he felt short of
breath and extremely dizzy. Looking closely at the medication ?
and turning to Google ? he figured out it was estrogen, not an
antidepressant, which patients should not abruptly quit.
?It was very apparent they were very understaffed,? Mr. Lewis said,
recalling long lines inside the Las Vegas store and at the
drive-through when he picked up the prescription. Pharmacists have
written to state regulatory boards about their safety concerns.
?My fellow pharmacists and pharmacy technicians are at our breaking
point. Chain pharmacy practices are preventing us from taking care
of our patients and putting them at risk of dangerous medication
errors.? New Jersey pharmacist
?The mistakes I have seen occur in this environment are both
frightening and understandable when we are under the gun to perform
the impossible. I?ve had a technician mix two strengths of a critical
blood pressure medication.? South Carolina pharmacist
?A fatigued and distracted pharmacist in a fast-paced, chaotic
environment is much more likely to make an error. The harm from a
medication error ranges from being a slight inconvenience to being
fatal.? Texas pharmacist
?Something needs to be done about this before lives are lost. Our
patients depend on us for their safety and wellness. We have to
live up to their expectations.? North Carolina pharmacist
?We are being asked to do things that we know at a gut level are
dangerous. If we won?t or can?t do them, our employers will find
someone else who will, and they will likely try to pay them less
for the same work.? South Carolina pharmacist
?We are forced to harass patients at check out to fill unnecessary
meds, request unnecessary refills, and to enroll in automatic fill
programs that result in dangerous duplications and meds to be filled
that were intended for single time use.? Missouri pharmacist Too
Much, Too Fast
The day before Wesley Hickman quit his job as a pharmacist at CVS,
he worked a 13-hour shift with no breaks for lunch or dinner, he
said.
As the only pharmacist on duty that day at the Leland, N.C., store,
Dr. Hickman filled 552 prescriptions ? about one every minute and
25 seconds ? while counseling patients, giving shots, making calls
and staffing the drive-through, he said. Partway through his shift
the next day, in December 2018, he called his manager.
?I said, ?I am not going to work in a situation that is unsafe.?
I shut the door and left,? said Dr. Hickman, who now runs an
independent pharmacy.
Dr. Hickman felt that the multitude of required tasks distracted
from his most important jobs: filling prescriptions accurately and
counseling patients. He had begged his district manager to schedule
more pharmacists, but the request was denied, he said.
CVS said it could not comment on the ?individual concerns? of a
former employee.
With nearly 10,000 pharmacies across the country, CVS is the largest
chain and among the most aggressive in imposing performance metrics,
pharmacists said. Both CVS and Walgreens tie bonuses to achieving
them, according to company documents.
Nearly everything is tracked and scrutinized: phone calls to
patients, the time it takes to fill a prescription, the number of
immunizations given, the number of customers signing up for 90-day
supplies of medication, to name a few.
The fact that tasks are being tracked is not the problem, pharmacists
say, as customers can benefit from services like reminders for flu
shots and refills. The issue is that employees are heavily evaluated
on hitting targets, they say, including in areas they cannot control.
In Missouri, dozens of pharmacists said in a recent survey by the
state board that the focus on metrics was a threat to patient safety
and their own job security.
?Metrics put unnecessary pressure on pharmacy staff to fill
prescriptions as fast as possible, resulting in errors,? one
pharmacist wrote.
Of the nearly 1,000 pharmacists who took the survey, 60 percent
said they ?agree? or ?strongly agree? that they ?feel pressured or
intimidated to meet standards or metrics that may interfere with
safe patient care.? About 60 percent of respondents worked for
retail chains, as opposed to hospitals or independent pharmacies.
Surveys in Maryland and Tennessee revealed similar concerns.
The specific goals are not made public, and can vary by store, but
internal CVS documents reviewed by The Times show what was expected
in some locations last year.
Staff members were supposed to persuade 65 percent of patients
picking up prescriptions to sign up for automatic refills, 55
percent to switch to 90-day supplies from 30-day, and 75 percent
to have the pharmacy contact their doctor with a ?proactive refill
request? if a prescription was expiring or had no refills, the
documents show.
Pharmacy staff members are also expected to call dozens of patients
each day, based on a computer-generated list. They are assessed on
the number of patients they reach, and the number who agree to
their requests.
Representatives from CVS and Walgreens said metrics were meant to
provide better patient care, not penalize pharmacists. Some are
related to reimbursements to pharmacies by insurance companies and
the government. CVS said it had halved its number of metrics over
the past 18 months.
But dozens of pharmacists described the emphasis on metrics as
burdensome, and said they faced backlash for failing to meet the
goals or suggesting they were unrealistic or unsafe.
?Any dissent perceived by corporate is met with a target placed on
one?s back,? an unnamed pharmacist wrote to the South Carolina
board last year.
In comments to state boards and interviews with The Times, pharmacists
explained how staffing cuts had led to longer shifts, often with
no break to use the restroom or eat.
?I certainly make more mistakes,? another South Carolina pharmacist
wrote to the board. ?I had two misfills in three years with the
previous staffing and now I make 10-12 per year (that are caught).?
Much of the blame for understaffing has been directed at pressure
from companies that manage drug plans for health insurers and
Medicare.
Acting as middlemen between drug manufacturers, insurers and
pharmacies, the companies ? known as pharmacy benefit managers, or
P.B.M.s ? negotiate prices and channel to pharmacies the more than
$300 billion spent on outpatient prescription drugs in the United
States annually.
The benefit managers charge fees to pharmacies, and have been widely
criticized for a lack of transparency and applying fees inconsistently.
In a letter to the Department of Health and Human Services in
September, a bipartisan group of senators noted an ?extraordinary
45,000 percent increase? in fees paid by pharmacies from 2010 to
2017.
While benefit managers have caused economic upheaval in the industry,
some pharmacy chains are players in that market too: CVS Health
owns CVS Caremark, the largest benefit manager; Walgreens Boots
Alliance has a partnership with Prime Therapeutics; Rite Aid owns
a P.B.M., too.
The Pharmaceutical Care Management Association, the trade group
representing benefit managers, contends that they make prescriptions
more affordable, and pushes back against the notion that P.B.M.s
are responsible for pressures on pharmacies, instead of a competitive
market. Pharmacists have written to state regulatory boards about
their safety concerns.
?I am expected to make 50-100 phone calls in addition to answering
phone calls, consultations, vaccinations and prescription verification.
This has resulted in dispensing errors. A member of our staff
misfilled a narcotic prescription for immediate release rather than
extended release which resulted luckily in only patient fatigue,
but it could have easily been deadly.? South Carolina pharmacist
?Thank the Lord I have not had any life-threatening misfills, but
I have had a number of ?minor? misfills mostly due to having to be
responsible for so many duties at once and constantly being pulled
away from verification to multitask.? South Carolina pharmacist
?I'm confident that I?ve had dispensing errors which have left my
pharmacy, but I was working too fast in order to meet our precious
metrics to notice them. Let's hope nobody suffered or died because
of it.? Missouri pharmacist
?I am currently a pharmacist working at CVS. I am writing to you
anonymously today as I fear for losing my job should my identity
be known; however, I feel it is my duty to bring our current
conditions to the board of pharmacy.? North Carolina pharmacist
?I've refrained from drinking fluids due to the fact that I couldn't
get to the restroom. I have ended up with kidney stones and infections
on more than one occasion.? South Carolina pharmacist
?There is so much pressure to work so quickly that there are nights
I go home just hoping I haven't made a mistake in all the craziness.
I work 8-10 hour shifts without a single break. Some days I go an
entire shift without finding any time to leave to use the restroom.?
Missouri pharmacist Falling Through the Cracks
Dr. Mark Lopatin, a rheumatologist in Pennsylvania, says he is
inundated with refill requests for almost every prescription he
writes. At times Dr. Lopatin prescribes drugs intended only for a
brief treatment ? a steroid to treat a flare-up of arthritis, for
instance.
But within days or weeks, he said, the pharmacy sends a refill
request even though the prescription did not call for one. Each
time, his office looks at the patient?s chart to confirm the request
is warranted. About half are not, he said.
Aside from creating unnecessary work, Dr. Lopatin believes, the
flood of requests poses a safety issue. ?When you are bombarded
with refill after refill, it?s easy for things to fall through the
cracks, despite your best efforts,? he said.
Pharmacists told The Times that many unwanted refill requests were
generated by automated systems designed in part to increase sales.
Others were the result of phone calls from pharmacists, who said
they faced pressure to reach quotas.
In February, a CVS pharmacist wrote to the South Carolina board
that cold calls to doctors should stop, explaining that a call was
considered ?successful? only if the doctor agreed to the refill.
?What this means is that we are overwhelming doctor?s office staff
with constant calls, and patients are often kept on medication that
is unneeded for extended periods of time,? the pharmacist wrote.
CVS says outreach to patients and doctors can help patients stay
up-to-date on their medications, and lead to lower costs and better
health.
Dr. Rachel Poliquin, a psychiatrist in North Carolina who says she
constantly gets refill requests, estimates that about 90 percent
of her patients say they never asked their pharmacy to contact her.
While Dr. Poliquin has a policy that patients must contact her
directly for more medication, she worries about clinics where
prescriptions may get rubber-stamped in a flurry of requests. Then
patients ? especially those who are elderly or mentally ill ? may
continue taking medication unnecessarily, she said.
The American Psychiatric Association has been trying to tackle a
related problem after hearing from members that CVS was giving
patients larger supplies of medication than doctors had directed.
While it is common for pharmacies to dispense 90 days? worth of
maintenance medications ? to treat chronic conditions like high
blood pressure or diabetes ? doctors say it is inappropriate for
other drugs.
For example, patients with bipolar disorder are often prescribed
lithium, a potentially lethal drug if taken in excess. It is common
for psychiatrists to start a patient on a low dose or to limit the
number of pills dispensed at once, especially if the person is
considered a suicide risk.
But increasingly, the psychiatric association has heard from members
that smaller quantities specified on prescriptions are being ignored,
particularly by CVS, according to Dr. Schwartz, the group?s president.
CVS has created a system where doctors can register and request
that 90-day supplies not be dispensed to their patients. But doctors
report that the registry has not solved the problem, Dr. Schwartz
said. In a statement, CVS said it continued to ?refine and enhance?
the program.
Dr. Charles Denby, a psychiatrist in Rhode Island, became so
concerned by the practice that he started stamping prescriptions,
?AT MONTHLY INTERVALS ONLY.? Despite those explicit instructions,
Dr. Denby said, he received faxes from CVS saying his patients had
asked for ? and been given ? 90-day supplies.
Dr. Denby, who retired in December, said it was a ?baldfaced lie?
that the patients had asked for the medication, providing statements
from patients saying as much.
?I am disgusted with this,? said Dr. Denby, who worries that patients
may attempt suicide with excess medication. ?There are going to be
people dead only because they have enough medication to do the deed
with.? ?We Already Have Systems in Place?
Alton James never learned how the mistake came about that he says
killed his 85-year-old mother, Mary Scheuerman, in 2018.
He knows he picked up her prescription at the pharmacy in a Publix
supermarket in Lakeland, Fla. He knows he gave her a pill each
morning. He knows that after six days, she turned pale, her blood
pressure dropped and she was rushed to the hospital. Image Mary
Scheuerman died in December 2018 after taking a powerful chemotherapy
drug mistakenly dispensed by a Publix pharmacy. Her son said she
was supposed to have received an antidepressant.
Mr. James remembers a doctor telling him his mother?s blood had a
toxic level of methotrexate, a drug often used to treat cancer.
But Mrs. Scheuerman didn?t have cancer. She was supposed to be
taking an antidepressant. Mr. James said a pharmacy employee later
confirmed that someone had mistakenly dispensed methotrexate.
Five days after entering the hospital, Mrs. Scheuerman died, with
organ failure listed as the lead cause, according to medical records
cited by Mr. James.
The Institute for Safe Medication Practices has warned about
methotrexate, listing it as a ?high-alert medication? that can be
deadly when taken incorrectly. Mr. James reported the pharmacy?s
error to the group, writing that he wanted to raise awareness about
the drug and push Publix, one of the country?s largest supermarket
chains, to ?clean up? its pharmacy division, according to a copy
of his report provided to The Times. Image Trexall, a brand name
for the drug methotrexate, can be used to treat cancer.
The company acknowledged the mistake and offered a settlement, Mr.
James wrote, but would not discuss how to avoid future errors,
saying, ?We already have systems in place.?
Last September, Mr. James told The Times that Publix wanted him to
sign a settlement agreement that would prevent him from speaking
further about his mother?s death. Mr. James has since declined to
comment, saying that the matter was ?amicably resolved.?
A spokeswoman for Publix said privacy laws prevented the company
from commenting on specific patients.
It can be difficult for patients and their families to decide
whether to accept a settlement.
Last summer, CVS offered to compensate Kelsey and Donavan Sullivan
after a pediatrician discovered the reflux medication they had been
giving their 4-month-old for two months was actually a steroid. To
be safely weaned, the baby had to keep taking it for two weeks
after the error was discovered.
?It was like he was coming out of a fog,? Mrs. Sullivan recalled.
The couple, from Minnesota, are still considering a settlement but
haven?t agreed to anything because they don?t know what long-term
consequences their son might face.
The kinds of errors and how they occur vary considerably.
The paper stapled to a CVS bag containing medication for Ms. Watrous,
the Connecticut teenager with asthma, listed her correct name and
medication, but the bottle inside had someone else?s name.
Directions on the prescription for Mr. Walker, the Illinois man
who got ear drops instead of eye drops from Walgreens, were clear:
?Instill 1 drop in both eyes every 6 hours.? He later saw the box:
?For use in ears only.?
In September, Stefanie Davis, 31, got the right medicine, Adderall,
but the wrong dose. She pulled over on the interstate after feeling
short of breath and dizzy with blurred vision. The pills, dispensed
by a Walgreens in Sun City Center, Fla., were each 30 milligrams
instead of her usual 20. She is fighting with Walgreens to cover
a $900 bill for her visit to an emergency room. Fixes That Fall
Short
State boards and legislatures have wrestled with how to regulate
the industry. Some states have adopted laws, for instance introducing
mandatory lunch breaks or limiting the number of technicians a
pharmacist can supervise.
But the laws aren?t always followed, can be difficult to enforce
or can fail to address broader problems.
The National Association of Chain Drug Stores says some state boards
are blocking meaningful change. The group, for instance, wants to
free up pharmacists from some tasks by allowing technicians, who
have less training, to do more.
It also supports efforts to change the insurance reimbursement
model for pharmacies. Health care services provided by pharmacists
to patients, such as prescribing birth control, are not consistently
covered by insurers or allowed in all states. But it has been
difficult to find consensus to change federal and state regulations.
While those debates continue, some state boards are trying to hold
companies more accountable.
Often when an error is reported to a board, action is taken against
the pharmacist, an obvious target. It is less common for a company
to be scrutinized.
The South Carolina board discussed in November how to more thoroughly
investigate conditions after a mistake. It also published a statement
discouraging quotas and encouraging ?employers to value patient
safety over operational efficiency and financial targets.?
California passed a law saying no pharmacist could be required to
work alone, but it has been largely ignored since taking effect
last year, according to leaders of a pharmacists? union. The state
board is trying to clarify the law?s requirements.
In Illinois, a new law requires breaks for pharmacists and potential
penalties for companies that do not provide a safe working environment.
The law was in response to a 2016 Chicago Tribune investigation
revealing that pharmacies failed to warn patients about dangerous
drug combinations.
Some states are trying to make changes behind closed doors. After
seeing results of its survey last year, the Missouri board invited
companies to private meetings early this year to answer questions
about errors, staffing and patient safety.
CVS and Walgreens said they would attend.
Research was contributed by Susan C. Beachy, Jack Begg, Alain
Delaquérière and Sheelagh McNeill.
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By Ellen Gabler
Jan. 31, 2020
For Alyssa Watrous, the medication mix-up meant a pounding headache,
nausea and dizziness. In September, Ms. Watrous, a 17-year-old from
Connecticut, was about to take another asthma pill when she realized
CVS had mistakenly given her blood pressure medication intended
for someone else.
Edward Walker, 38, landed in an emergency room, his eyes swollen
and burning after he put drops in them for five days in November
2018 to treat a mild irritation. A Walgreens in Illinois had
accidentally supplied him with ear drops ? not eye drops.
For Mary Scheuerman, 85, the error was discovered only when she
was dying in a Florida hospital in December 2018. A Publix pharmacy
had dispensed a powerful chemotherapy drug instead of the antidepressant
her doctor had prescribed. She died about two weeks later.
The people least surprised by such mistakes are pharmacists working
in some of the nation?s biggest retail chains.
In letters to state regulatory boards and in interviews with The
New York Times, many pharmacists at companies like CVS, Rite Aid
and Walgreens described understaffed and chaotic workplaces where
they said it had become difficult to perform their jobs safely,
putting the public at risk of medication errors.
They struggle to fill prescriptions, give flu shots, tend the
drive-through, answer phones, work the register, counsel patients
and call doctors and insurance companies, they said ? all the while
racing to meet corporate performance metrics that they characterized
as unreasonable and unsafe in an industry squeezed to do more with
less.
?I am a danger to the public working for CVS,? one pharmacist wrote
in an anonymous letter to the Texas State Board of Pharmacy in
April.
?The amount of busywork we must do while verifying prescriptions
is absolutely dangerous,? another wrote to the Pennsylvania board
in February. ?Mistakes are going to be made and the patients are
going to be the ones suffering.?
[Read how you can protect yourself against medication errors.]
State boards and associations in at least two dozen states have
heard from distraught pharmacists, interviews and records show,
while some doctors complain that pharmacies bombard them with
requests for refills that patients have not asked for and should
not receive. Such refills are closely tracked by pharmacy chains
and can factor into employee bonuses.
Michael Jackson, chief executive of the Florida Pharmacy Association,
said the number of complaints from members related to staffing cuts
and worries about patient safety had become ?overwhelming? in the
past year. ImageCVS Health ranks eighth on the Fortune 500 list
and has nearly 10,000 pharmacies across the United States. CVS
Health ranks eighth on the Fortune 500 list and has nearly 10,000
pharmacies across the United States.Credit...Jeenah Moon for The
New York Times
The American Psychiatric Association is particularly concerned
about CVS, America?s eighth-largest company, which it says routinely
ignores doctors? explicit instructions to dispense limited amounts
of medication to mental health patients. The pharmacy?s practice
of providing three-month supplies may inadvertently lead more
patients to attempt suicide by overdosing, the association said.
?Clearly it is financially in their best interest to dispense as
many pills as they can get paid for,? said Dr. Bruce Schwartz, a
psychiatrist in New York and the group?s president.
A spokesman for CVS said it had created a system to address the
issue, but Dr. Schwartz said complaints persisted.
Regulating the chains ? five rank among the nation?s 100 largest
companies ? has proved difficult for state pharmacy boards, which
oversee the industry but sometimes allow company representatives
to hold seats. Florida?s nine-member board, for instance, includes
a lawyer for CVS and a director of pharmacy affairs at Walgreens.
Aside from creating potential conflicts of interest, the industry
presence can stifle complaints. ?We are afraid to speak up and lose
our jobs,? one pharmacist wrote anonymously last year in response
to a survey by the Missouri Board of Pharmacy. ?PLEASE HELP."
Officials from several state boards told The Times they had limited
authority to dictate how companies ran their businesses. Efforts
by legislatures in California and elsewhere have been unsuccessful
in substantially changing how pharmacies operate.
A majority of state boards do not require pharmacies to report
errors, let alone conduct thorough investigations when they occur.
Most investigations focus on pharmacists, not the conditions in
their workplaces.
In public meetings, boards in at least two states have instructed
pharmacists to quit or speak up if they believe conditions are
unsafe. But pharmacists said they feared retaliation, knowing they
could easily be replaced.
The industry has been squeezed amid declining drug reimbursement
rates and cost pressures from administrators of prescription drug
plans. Consolidation, meanwhile, has left only a few major players.
About 70 percent of prescriptions nationwide are dispensed by chain
drugstores, supermarkets or retailers like Walmart, according to
a 2019 Drug Channels Institute report.
CVS garners a quarter of the country?s total prescription revenue
and dispenses more than a billion prescriptions a year. Walgreens
captures almost 20 percent. Walmart, Kroger and Rite Aid fall next
in line among brick-and-mortar stores.
In statements, the pharmacy chains said patient safety was of utmost
concern, with staffing carefully set to ensure accurate dispensing.
Investment in technology such as e-prescribing has increased safety
and efficiency, the companies said. They denied that pharmacists
were under extreme pressure or faced reprisals.
?When a pharmacist has a legitimate concern about working conditions,
we make every effort to address that concern in good faith,? CVS
said in a statement. Walgreens cited its confidential employee
hotline and said it made ?clear to all pharmacists that they should
never work beyond what they believe is advisable.?
Errors, the companies said, were regrettable but rare; they declined
to provide data about mistakes.
The National Association of Chain Drug Stores, a trade group, said
that ?pharmacies consider even one prescription error to be one
too many? and ?seek continuous improvement.? The organization said
it was wrong to ?assume cause-effect relationships? between errors
and pharmacists? workload.
The specifics and severity of errors are nearly impossible to tally.
Aside from lax reporting requirements, many mistakes never become
public because companies settle with victims or their families,
often requiring a confidentiality agreement. A CVS form for staff
members to report errors asks whether the patient is a ?media
threat,? according to a photo provided to The Times. CVS said in
a statement it would not provide details on what it called its
?escalation process.?
The last comprehensive study of medication errors was over a decade
ago: The Institute of Medicine estimated in 2006 that such mistakes
harmed at least 1.5 million Americans each year.
Jonathan Lewis said he waited on hold with CVS for 40 minutes last
summer, after discovering his antidepressant prescription had been
refilled with another drug.
Mr. Lewis, 47, suspected something was wrong when he felt short of
breath and extremely dizzy. Looking closely at the medication ?
and turning to Google ? he figured out it was estrogen, not an
antidepressant, which patients should not abruptly quit.
?It was very apparent they were very understaffed,? Mr. Lewis said,
recalling long lines inside the Las Vegas store and at the
drive-through when he picked up the prescription. Pharmacists have
written to state regulatory boards about their safety concerns.
?My fellow pharmacists and pharmacy technicians are at our breaking
point. Chain pharmacy practices are preventing us from taking care
of our patients and putting them at risk of dangerous medication
errors.? New Jersey pharmacist
?The mistakes I have seen occur in this environment are both
frightening and understandable when we are under the gun to perform
the impossible. I?ve had a technician mix two strengths of a critical
blood pressure medication.? South Carolina pharmacist
?A fatigued and distracted pharmacist in a fast-paced, chaotic
environment is much more likely to make an error. The harm from a
medication error ranges from being a slight inconvenience to being
fatal.? Texas pharmacist
?Something needs to be done about this before lives are lost. Our
patients depend on us for their safety and wellness. We have to
live up to their expectations.? North Carolina pharmacist
?We are being asked to do things that we know at a gut level are
dangerous. If we won?t or can?t do them, our employers will find
someone else who will, and they will likely try to pay them less
for the same work.? South Carolina pharmacist
?We are forced to harass patients at check out to fill unnecessary
meds, request unnecessary refills, and to enroll in automatic fill
programs that result in dangerous duplications and meds to be filled
that were intended for single time use.? Missouri pharmacist Too
Much, Too Fast
The day before Wesley Hickman quit his job as a pharmacist at CVS,
he worked a 13-hour shift with no breaks for lunch or dinner, he
said.
As the only pharmacist on duty that day at the Leland, N.C., store,
Dr. Hickman filled 552 prescriptions ? about one every minute and
25 seconds ? while counseling patients, giving shots, making calls
and staffing the drive-through, he said. Partway through his shift
the next day, in December 2018, he called his manager.
?I said, ?I am not going to work in a situation that is unsafe.?
I shut the door and left,? said Dr. Hickman, who now runs an
independent pharmacy.
Dr. Hickman felt that the multitude of required tasks distracted
from his most important jobs: filling prescriptions accurately and
counseling patients. He had begged his district manager to schedule
more pharmacists, but the request was denied, he said.
CVS said it could not comment on the ?individual concerns? of a
former employee.
With nearly 10,000 pharmacies across the country, CVS is the largest
chain and among the most aggressive in imposing performance metrics,
pharmacists said. Both CVS and Walgreens tie bonuses to achieving
them, according to company documents.
Nearly everything is tracked and scrutinized: phone calls to
patients, the time it takes to fill a prescription, the number of
immunizations given, the number of customers signing up for 90-day
supplies of medication, to name a few.
The fact that tasks are being tracked is not the problem, pharmacists
say, as customers can benefit from services like reminders for flu
shots and refills. The issue is that employees are heavily evaluated
on hitting targets, they say, including in areas they cannot control.
In Missouri, dozens of pharmacists said in a recent survey by the
state board that the focus on metrics was a threat to patient safety
and their own job security.
?Metrics put unnecessary pressure on pharmacy staff to fill
prescriptions as fast as possible, resulting in errors,? one
pharmacist wrote.
Of the nearly 1,000 pharmacists who took the survey, 60 percent
said they ?agree? or ?strongly agree? that they ?feel pressured or
intimidated to meet standards or metrics that may interfere with
safe patient care.? About 60 percent of respondents worked for
retail chains, as opposed to hospitals or independent pharmacies.
Surveys in Maryland and Tennessee revealed similar concerns.
The specific goals are not made public, and can vary by store, but
internal CVS documents reviewed by The Times show what was expected
in some locations last year.
Staff members were supposed to persuade 65 percent of patients
picking up prescriptions to sign up for automatic refills, 55
percent to switch to 90-day supplies from 30-day, and 75 percent
to have the pharmacy contact their doctor with a ?proactive refill
request? if a prescription was expiring or had no refills, the
documents show.
Pharmacy staff members are also expected to call dozens of patients
each day, based on a computer-generated list. They are assessed on
the number of patients they reach, and the number who agree to
their requests.
Representatives from CVS and Walgreens said metrics were meant to
provide better patient care, not penalize pharmacists. Some are
related to reimbursements to pharmacies by insurance companies and
the government. CVS said it had halved its number of metrics over
the past 18 months.
But dozens of pharmacists described the emphasis on metrics as
burdensome, and said they faced backlash for failing to meet the
goals or suggesting they were unrealistic or unsafe.
?Any dissent perceived by corporate is met with a target placed on
one?s back,? an unnamed pharmacist wrote to the South Carolina
board last year.
In comments to state boards and interviews with The Times, pharmacists
explained how staffing cuts had led to longer shifts, often with
no break to use the restroom or eat.
?I certainly make more mistakes,? another South Carolina pharmacist
wrote to the board. ?I had two misfills in three years with the
previous staffing and now I make 10-12 per year (that are caught).?
Much of the blame for understaffing has been directed at pressure
from companies that manage drug plans for health insurers and
Medicare.
Acting as middlemen between drug manufacturers, insurers and
pharmacies, the companies ? known as pharmacy benefit managers, or
P.B.M.s ? negotiate prices and channel to pharmacies the more than
$300 billion spent on outpatient prescription drugs in the United
States annually.
The benefit managers charge fees to pharmacies, and have been widely
criticized for a lack of transparency and applying fees inconsistently.
In a letter to the Department of Health and Human Services in
September, a bipartisan group of senators noted an ?extraordinary
45,000 percent increase? in fees paid by pharmacies from 2010 to
2017.
While benefit managers have caused economic upheaval in the industry,
some pharmacy chains are players in that market too: CVS Health
owns CVS Caremark, the largest benefit manager; Walgreens Boots
Alliance has a partnership with Prime Therapeutics; Rite Aid owns
a P.B.M., too.
The Pharmaceutical Care Management Association, the trade group
representing benefit managers, contends that they make prescriptions
more affordable, and pushes back against the notion that P.B.M.s
are responsible for pressures on pharmacies, instead of a competitive
market. Pharmacists have written to state regulatory boards about
their safety concerns.
?I am expected to make 50-100 phone calls in addition to answering
phone calls, consultations, vaccinations and prescription verification.
This has resulted in dispensing errors. A member of our staff
misfilled a narcotic prescription for immediate release rather than
extended release which resulted luckily in only patient fatigue,
but it could have easily been deadly.? South Carolina pharmacist
?Thank the Lord I have not had any life-threatening misfills, but
I have had a number of ?minor? misfills mostly due to having to be
responsible for so many duties at once and constantly being pulled
away from verification to multitask.? South Carolina pharmacist
?I'm confident that I?ve had dispensing errors which have left my
pharmacy, but I was working too fast in order to meet our precious
metrics to notice them. Let's hope nobody suffered or died because
of it.? Missouri pharmacist
?I am currently a pharmacist working at CVS. I am writing to you
anonymously today as I fear for losing my job should my identity
be known; however, I feel it is my duty to bring our current
conditions to the board of pharmacy.? North Carolina pharmacist
?I've refrained from drinking fluids due to the fact that I couldn't
get to the restroom. I have ended up with kidney stones and infections
on more than one occasion.? South Carolina pharmacist
?There is so much pressure to work so quickly that there are nights
I go home just hoping I haven't made a mistake in all the craziness.
I work 8-10 hour shifts without a single break. Some days I go an
entire shift without finding any time to leave to use the restroom.?
Missouri pharmacist Falling Through the Cracks
Dr. Mark Lopatin, a rheumatologist in Pennsylvania, says he is
inundated with refill requests for almost every prescription he
writes. At times Dr. Lopatin prescribes drugs intended only for a
brief treatment ? a steroid to treat a flare-up of arthritis, for
instance.
But within days or weeks, he said, the pharmacy sends a refill
request even though the prescription did not call for one. Each
time, his office looks at the patient?s chart to confirm the request
is warranted. About half are not, he said.
Aside from creating unnecessary work, Dr. Lopatin believes, the
flood of requests poses a safety issue. ?When you are bombarded
with refill after refill, it?s easy for things to fall through the
cracks, despite your best efforts,? he said.
Pharmacists told The Times that many unwanted refill requests were
generated by automated systems designed in part to increase sales.
Others were the result of phone calls from pharmacists, who said
they faced pressure to reach quotas.
In February, a CVS pharmacist wrote to the South Carolina board
that cold calls to doctors should stop, explaining that a call was
considered ?successful? only if the doctor agreed to the refill.
?What this means is that we are overwhelming doctor?s office staff
with constant calls, and patients are often kept on medication that
is unneeded for extended periods of time,? the pharmacist wrote.
CVS says outreach to patients and doctors can help patients stay
up-to-date on their medications, and lead to lower costs and better
health.
Dr. Rachel Poliquin, a psychiatrist in North Carolina who says she
constantly gets refill requests, estimates that about 90 percent
of her patients say they never asked their pharmacy to contact her.
While Dr. Poliquin has a policy that patients must contact her
directly for more medication, she worries about clinics where
prescriptions may get rubber-stamped in a flurry of requests. Then
patients ? especially those who are elderly or mentally ill ? may
continue taking medication unnecessarily, she said.
The American Psychiatric Association has been trying to tackle a
related problem after hearing from members that CVS was giving
patients larger supplies of medication than doctors had directed.
While it is common for pharmacies to dispense 90 days? worth of
maintenance medications ? to treat chronic conditions like high
blood pressure or diabetes ? doctors say it is inappropriate for
other drugs.
For example, patients with bipolar disorder are often prescribed
lithium, a potentially lethal drug if taken in excess. It is common
for psychiatrists to start a patient on a low dose or to limit the
number of pills dispensed at once, especially if the person is
considered a suicide risk.
But increasingly, the psychiatric association has heard from members
that smaller quantities specified on prescriptions are being ignored,
particularly by CVS, according to Dr. Schwartz, the group?s president.
CVS has created a system where doctors can register and request
that 90-day supplies not be dispensed to their patients. But doctors
report that the registry has not solved the problem, Dr. Schwartz
said. In a statement, CVS said it continued to ?refine and enhance?
the program.
Dr. Charles Denby, a psychiatrist in Rhode Island, became so
concerned by the practice that he started stamping prescriptions,
?AT MONTHLY INTERVALS ONLY.? Despite those explicit instructions,
Dr. Denby said, he received faxes from CVS saying his patients had
asked for ? and been given ? 90-day supplies.
Dr. Denby, who retired in December, said it was a ?baldfaced lie?
that the patients had asked for the medication, providing statements
from patients saying as much.
?I am disgusted with this,? said Dr. Denby, who worries that patients
may attempt suicide with excess medication. ?There are going to be
people dead only because they have enough medication to do the deed
with.? ?We Already Have Systems in Place?
Alton James never learned how the mistake came about that he says
killed his 85-year-old mother, Mary Scheuerman, in 2018.
He knows he picked up her prescription at the pharmacy in a Publix
supermarket in Lakeland, Fla. He knows he gave her a pill each
morning. He knows that after six days, she turned pale, her blood
pressure dropped and she was rushed to the hospital. Image Mary
Scheuerman died in December 2018 after taking a powerful chemotherapy
drug mistakenly dispensed by a Publix pharmacy. Her son said she
was supposed to have received an antidepressant.
Mr. James remembers a doctor telling him his mother?s blood had a
toxic level of methotrexate, a drug often used to treat cancer.
But Mrs. Scheuerman didn?t have cancer. She was supposed to be
taking an antidepressant. Mr. James said a pharmacy employee later
confirmed that someone had mistakenly dispensed methotrexate.
Five days after entering the hospital, Mrs. Scheuerman died, with
organ failure listed as the lead cause, according to medical records
cited by Mr. James.
The Institute for Safe Medication Practices has warned about
methotrexate, listing it as a ?high-alert medication? that can be
deadly when taken incorrectly. Mr. James reported the pharmacy?s
error to the group, writing that he wanted to raise awareness about
the drug and push Publix, one of the country?s largest supermarket
chains, to ?clean up? its pharmacy division, according to a copy
of his report provided to The Times. Image Trexall, a brand name
for the drug methotrexate, can be used to treat cancer.
The company acknowledged the mistake and offered a settlement, Mr.
James wrote, but would not discuss how to avoid future errors,
saying, ?We already have systems in place.?
Last September, Mr. James told The Times that Publix wanted him to
sign a settlement agreement that would prevent him from speaking
further about his mother?s death. Mr. James has since declined to
comment, saying that the matter was ?amicably resolved.?
A spokeswoman for Publix said privacy laws prevented the company
from commenting on specific patients.
It can be difficult for patients and their families to decide
whether to accept a settlement.
Last summer, CVS offered to compensate Kelsey and Donavan Sullivan
after a pediatrician discovered the reflux medication they had been
giving their 4-month-old for two months was actually a steroid. To
be safely weaned, the baby had to keep taking it for two weeks
after the error was discovered.
?It was like he was coming out of a fog,? Mrs. Sullivan recalled.
The couple, from Minnesota, are still considering a settlement but
haven?t agreed to anything because they don?t know what long-term
consequences their son might face.
The kinds of errors and how they occur vary considerably.
The paper stapled to a CVS bag containing medication for Ms. Watrous,
the Connecticut teenager with asthma, listed her correct name and
medication, but the bottle inside had someone else?s name.
Directions on the prescription for Mr. Walker, the Illinois man
who got ear drops instead of eye drops from Walgreens, were clear:
?Instill 1 drop in both eyes every 6 hours.? He later saw the box:
?For use in ears only.?
In September, Stefanie Davis, 31, got the right medicine, Adderall,
but the wrong dose. She pulled over on the interstate after feeling
short of breath and dizzy with blurred vision. The pills, dispensed
by a Walgreens in Sun City Center, Fla., were each 30 milligrams
instead of her usual 20. She is fighting with Walgreens to cover
a $900 bill for her visit to an emergency room. Fixes That Fall
Short
State boards and legislatures have wrestled with how to regulate
the industry. Some states have adopted laws, for instance introducing
mandatory lunch breaks or limiting the number of technicians a
pharmacist can supervise.
But the laws aren?t always followed, can be difficult to enforce
or can fail to address broader problems.
The National Association of Chain Drug Stores says some state boards
are blocking meaningful change. The group, for instance, wants to
free up pharmacists from some tasks by allowing technicians, who
have less training, to do more.
It also supports efforts to change the insurance reimbursement
model for pharmacies. Health care services provided by pharmacists
to patients, such as prescribing birth control, are not consistently
covered by insurers or allowed in all states. But it has been
difficult to find consensus to change federal and state regulations.
While those debates continue, some state boards are trying to hold
companies more accountable.
Often when an error is reported to a board, action is taken against
the pharmacist, an obvious target. It is less common for a company
to be scrutinized.
The South Carolina board discussed in November how to more thoroughly
investigate conditions after a mistake. It also published a statement
discouraging quotas and encouraging ?employers to value patient
safety over operational efficiency and financial targets.?
California passed a law saying no pharmacist could be required to
work alone, but it has been largely ignored since taking effect
last year, according to leaders of a pharmacists? union. The state
board is trying to clarify the law?s requirements.
In Illinois, a new law requires breaks for pharmacists and potential
penalties for companies that do not provide a safe working environment.
The law was in response to a 2016 Chicago Tribune investigation
revealing that pharmacies failed to warn patients about dangerous
drug combinations.
Some states are trying to make changes behind closed doors. After
seeing results of its survey last year, the Missouri board invited
companies to private meetings early this year to answer questions
about errors, staffing and patient safety.
CVS and Walgreens said they would attend.
Research was contributed by Susan C. Beachy, Jack Begg, Alain
Delaquérière and Sheelagh McNeill.
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