The drug interaction debacle — Was it metrics or margins?
Thursday, February 16, 2017
A Dec. 15, 2016 article in the Chicago Tribune titled "Pharmacies miss half of dangerous drug combinations" is getting noticed.
According to the investigative research conducted by Tribune staff, pharmacies overwhelmingly failed to notify physicians and patients about potentially serious drug interactions. The reporters visited 255 pharmacies and presented a pair of prescriptions with known drug interactions.
Just how bad did the pharmacies do? A failure to warn patients or call a doctor happened 52 percent of the time. Most of those who have been commenting on this report appear to be stunned, amazed and disappointed.
Carmen Catizone, executive director of the National Association of Boards of Pharmacy told the Tribune, "Anytime there's a serious interaction, there's no excuse for the pharmacist not warning the patient about the interaction." The Tribune itself, in commenting on the significance of this situation, said it "exposes fundamental flaws in the pharmacy industry. Safety laws are not being followed, computer alert systems designed to flag drug interactions either don't work or are ignored, and some pharmacies emphasize fast service over patient safety."
Metrics are often blamed as the root cause of many failures within the retail dispensing business. The Tribune article, for example, spends some time exposing the many metrics that pharmacies must meet to comply with company goals: "[T]he company tracks numerous pharmacist tasks, including whether prescriptions are filled in the time promised to customers and whether voicemails are retrieved in a timely fashion."
Daniel Hussar, author of the well-respected Pharmacist Activist blog, calls the failure to address the drug interactions "abysmal and alarming." Hussar, in the title of his blog post on this problem, warns pharmacists to "Be on Guard and Stand Your Ground Against Metrics!"
He sounds the alarm to all practicing pharmacists: "We must insist on having the time needed to fulfill our primary responsibilities to patients in the manner of which we are capable. And we should also take the time to document these situations and our interventions. If the lines of patients waiting to obtain prescriptions get even longer, so be it."
However, there is another even bigger story behind the missed drug interactions. Metrics are an easy target to blame, since we all see how much pressure they put on pharmacy staff to work faster and faster in an already hectic environment. But what is not being talked about is the other "M" word lurking behind the metrics and driving this dangerously fast-paced model: margins.
Those who don't actually work at running a pharmacy may be unaware of the fact that the retail pharmacy business has been on a downward spiral of accepting lower and lower reimbursements from insurance companies for years. When you can, at best, hope to make a few dollars on a prescription (and often we lose money these days), your only hope for survival is volume.
Metrics are just a tool to drive volume due to declining margins. Metrics are not inherently evil. Many businesses use some type of metrics — often called key performance indicators, or KPIs — to monitor the efficiency of their processes.
The problem in pharmacy is low margins require that prescription-filling goals must be set dangerously high to survive. This analysis explains why, in my opinion, independent pharmacies fared the worst in catching drug interactions. They have an even harder time surviving because they don't have the buying power of the big chains.
In a nutshell, we have allowed retail pharmacy dispensing to follow a pattern of business developed by the fast food industry.
I have worked in a variety of healthcare settings. There is simply no other health business that runs like pharmacy runs. This drug interaction debacle has uncovered and revealed that this is what you get when you want drive-through drug dispensing.
Unfortunately, we have gone so far down this road that the only way back may be legislation. For example, if boards of pharmacy push for limits on the number of prescriptions per hour that can be safely checked, the big chains will have to push for higher margins to survive.
Yes, this will drive up costs, but this is one area of healthcare that costs actually need to go up. Patient safety demands that pharmacies are paid fairly enough to cover the costs of checking prescriptions and educating consumers.
The mind-numbing pace makes it much less likely that pharmacists will catch dangerous drug interactions like the ones in the Chicago Tribune story. Other factors that may have contributed to the situation could be poorly designed software that treats all potential interactions the same, pharmacist fatigue, staffing, communication, differences in professional judgment or assumptions and prescription volume.
In reality, there isn't one perfect explanation for why so many prescription interactions were missed by these pharmacists. The truth is never usually that simple. But as a profession we do need to work together on an answer if we want to keep this sort of thing from happening again.
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