Emily Whitman: The Wrong Rx for America

I loved the local, independent pharmacy where I used to work. So did our customers. Sadly, their health will suffer now that we're gone.

Robot selecting medications from a pharmacy storage shelf. (Wikimedia Commons)

By Emily Whitman

A few years ago, my husband and I bought a home in a sweet town in upstate New York full of small businesses. I took a job at the local pharmacy. I love it. I got to know my neighbors and felt part of the community. 

The pharmacy has been here since the 1960s. On a typical day, at least three or four folks will pick up their medication, then spend a good ten minutes discussing soccer or fishing or their family with staff. We know every person by name. We deliver to a few of our elderly patients off the clock because they can’t always find a ride. We cut breaks to folks who are temporarily uninsured so they can still afford what they need. They trust us and we earn that trust every day.

It’s neighborly love. It’s heartwarming. It’s quaint. 

It’s just been put out of business by CVS.

Independent pharmacies struggle to compete for various reasons, but the short version is that chains like CVS and Walgreens get better reimbursements from insurance companies and lower prices from medication suppliers. The deck is stacked against independents for many reasons, but most importantly through what are known in the business as PBMs (pharmacy benefit managers): powerful firms that work with insurers to negotiate which drugs get covered and which don’t.

Pharmacies are forced to work with PBMs to get paid when they fill prescriptions. Big pharmacies have more power to negotiate and meet sales benchmarks, lowering their costs. Smaller, independent pharmacies don’t. So they can’t compete, and eventually close their doors.

How bad is it? The Washington Post reports that “From 2003 to 2018, 1,231 of the nation’s 7,624 independent rural pharmacies closed, according to the University of Iowa’s Rural Policy Research Institute, leaving 630 communities with no independent or chain retail drugstore.”

In case you don’t have time to read the whole WaPo story, its headline and subhead read: The last drugstore: Rural America is losing its pharmacies—Over 40 million rural Americans live in pharmacy deserts because of market consolidation.

Legislation was introduced last year to help level the playing field. But even if it passes—a longshot in today’s Washington—it won’t be in time to save my lovely town from being fed to the monopolists. 

High prices aren’t the only problem with mindless consolidation. Too often life-threatening mistakes are made due to the pressure of volume metrics and the rush to fill prescriptions as fast as humanly—and robotically—possible.

As The New York Times reported in 2020, “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.”

Caring, local pharmacists are our last line of defense against these kinds of mistakes and health risks. And our customers get it. But what can they do? Since the news broke of our closing, it’s been a parade of heartbroken people telling me they used to buy penny candy and baseball cards here when they were kids. I’ve had to bring out a box of tissues. They all want to know where the staff is going so they can follow us. They keep saying, “You’re like family.”

The store is closing, and CVS is buying all patient files, transferring them to their nearest location. They’ve offered to hire us, but quite frankly, I’d rather chew glass. Why? Because the death of independent pharmacies is a microcosm of our broken healthcare system: patient care under the thumb of corporate profit.

For years CVS and other mega pharmacies have been chipping away at skilled work and replacing expertise with a factory system—a model suited to high turnover as techs can train quickly, leaning on technology to perform tasks that once required knowledge and experience. The staff doesn’t answer the phone anymore. Customers leave messages that are poorly transcribed and garbled. Pharmacists don’t touch pill bottles now. They view photos of the contents. At Walmart, some stores have conveyor belts. 

The unspoken goal of such a system is to depress wages. What market value is there in scanning a bottle and taking a picture of tablets? Why not outsource technician and pharmacist tasks if data entry and verification can be done remotely, if algorithms can replace education? 

CVS will tell you their approach alleviates burnout and frees up pharmacists for consultations and vaccinations. They say it’s better for staff. I’d invite you to look into the eyes of the staff and listen to their tone of voice. That’s my complete rebuttal. A pharmacist I know who worked for Amazon’s pharmacy said the company monitored his mouse movements on the computer to ensure he was continuously working. CVS will say the system is more efficient and convenient for customers. Well, health care isn’t fast food. 

For Christmas one year, our senior pharmacist was given a coffee mug that says, “I’m a doctor of pharmacy. I keep medical doctors from killing you.” It’s funny because it’s true. As patients become increasingly unknown to their providers, bouncing between interns, the hometown pharmacist is the last line of defense against medical errors. 

And it takes a team. Techs don’t just label bottles. Fully credentialed pharmacy technicians (CPhTs) are highly knowledgeable professionals who have studied drug forms, indications, classes, dosing, and pharmacy law among other essentials of the field, and they are required to continue their studies, to keep up with changes just as pharmacists do. It’s their job to catch mistakes before your prescription gets to the busy pharmacist’s final check. The chains require less education than hospitals do (state licensure but not national certification), no study of new medications, less rigorous testing. Uncertified techs are cheaper.

Our job requires judgment you can’t feed into an algorithm. We know our patients’ medications and medical histories. When an algorithm would say, “no interactions, no allergies, all clear,” we might say, “She doesn’t take extended release. The doctor might have selected the wrong form.” Or, “He has been taking a much lower dose. The doctor may have selected the wrong strength.” Or, “She takes a supplement that increases serotonin levels. Did the doctor ask about supplements?” Doctors make mistakes. We catch them. 

A survey of NIH literature will show you that the chain pharmacy model is predisposed to higher rates of error and poorer patient care. In short, people—not robots—should be doing this job. Up to 40% of hospital admissions and 22% of readmissions result from medication errors. Patients taking five or more medications are 30% more likely and the elderly are 38% more likely to experience an error. Reasons for these errors read like a page from the chain pharmacy playbook: poor communication with patients and providers, high dispensing volume, inadequate drug knowledge, unavailable or inaccurate patient information, overwhelmed staff.

There’s also evidence that closure of independent pharmacies, where patients are often known by name, leads to higher nonadherence to prescription medications. In other words, you’re more likely to go off your meds if you get them by mail or at a massive chain where no one knows you.

So where are we headed? Generations who want a personal touch will be replaced by those who have grown up with self-checkouts and DoorDash. The value of face-to-face relationships is being socialized out of them. They are not only comfortable with technological mediation, but many prefer it. And even if they don’t, a monopolized market won’t give them a choice. 

I want to be very clear that I am not impugning the good hearts of CVS employees. I know many fine techs and pharmacists who work for chains. You probably don’t have a choice about using a chain any more than they have a choice about working for one. Why? Because all the independents are disappearing. Many want to give personal care, and they are connected to their communities, but it’s much harder for them to do their job properly within corporate constraints.

Given the exponential rate at which technology develops, and the corporate prioritizing of profit over patients, shareholders over staff, and capital over community—this is just the beginning. 

Unless we demand otherwise. Soon.

Emily Whitman, a pseudonym, is a fully credentialed pharmacy technician (CPhT) who fears losing her livelihood if her real name is disclosed.