Sunday, February 1, 2015

Pharmacies with in-store clinics shouldn't control which drugs are prescribed

When you think of Walgreens or CVS you probably have a drugstore in mind. But more and more, as people seek easier and less costly access to pressing health care needs than a hospital emergency department, people are visiting chain pharmacy locations for their in-store medical clinics. This is only going to grow given doctor shortages, especially as 30 million newly insured Americans begin to benefit from the Affordable Care Act.

Pharmacies with in-store clinics shouldn’t control which drugs are prescribed

When you think of Walgreens or CVS you probably have a drugstore in mind. But more and more, as people seek easier and less costly access to pressing health care needs than a hospital emergency department, people are visiting chain pharmacy locations for their in-store medical clinics. This is only going to grow given doctor shortages, especially as 30 million newly insured Americans begin to benefit from the Affordable Care Act.

When my wife got sick recently while we were out of state on vacation, we decided to stop by one of Walgreens “Take Care” in-store clinics. The experience led to some interesting observations.

First, I have to say the clinic was a great convenience compared to an experience we’d had just hours before when we went to a nearby hospital emergency room. My wife, who is a registered nurse, had an infection and the antibiotic her personal physician had prescribed wasn’t working. She called him and he recommended that she see someone in the city we were in. So we went to the hospital ER and, after waiting for an hour and a half sitting next to people coughing and sneezing, and still not being seen, we decided to leave. ER staff warned us that she’d be charged since we already signed in and she had her temperature taken along with blood pressure and weight. I got the bill in the mail recently. It was over $600! They did give us a $300 non-insured patient discount. We are insured but they hadn’t asked us for her card before being seen. I’ve since called the hospital to give them our insurance information so we’ll have to see what the final charge is.

These in-store clinics are generally open after-hours and on weekends and staffed by nurse practitioners (NP) or physician assistants (PA). We were charged only $35 for the visit plus the lab cost for her culture, which was also reasonable. Costs may at least be partially covered by insurance. The clinic contracts with an off-site physician who oversees the care provided and approves the treatment protocols they use. They treat minor injuries and illnesses like sore throats, urinary tract infections, cough and cold, pink eye, ear ache, sinus infection, etc. They also administer vaccines and can write prescriptions. Lately they’ve also taken on chronic disease monitoring too for conditions like diabetes, hypertension, high cholesterol and asthma, so it looks like the clinics are going to provide stiff competition for doctors in family practice. It’s not hard to understand the tremendous impact this is going to have on healthcare and especially family physician practices. I know many of them have been taking a close look at this competition to better understand how to best respond.

The Walgreens NP was very professional and kind and also quite knowledgeable. We waited only about 5 minutes before we were seen and we also had time to chat, so we asked her about her experience. I was very surprised to learn that during any down time Walgreens actually expects the NPs to go out into the store and promote the clinic with people waiting for prescriptions. She said she’s refused to do this because she feels it is unprofessional, but the expectation is there that she will and some of her colleagues have done this.

 

As a pharmacist, there was something that struck me as potentially problematic with the relationship between the pharmacy and the clinic. When the antibiotic was prescribed it was done electronically. That’s fine, but without asking us she sent it as a matter of routine directly to the in-store pharmacy. When we asked for the prescription she said immediately, “Oh, did you want it sent somewhere else… I can do that.” She had no motive other than this is what always happens and what patients always seemed to want. Prescriptions from the clinic are probably not a giant source of income for Walgreens (usually small change and a low volume of generic prescriptions) but it did make me think something just wasn’t quite right about it.  

I’ve criticized physicians who profit from selling drugs in their office. There’s a sense of unease regarding a potential conflict of interest when the physician prescribing the medication is also the person dispensing the medication and, perhaps, making a profit from the sale.  It brings up serious medication safety concerns, particularly the loss of a crucial independent check by a pharmacist. With the in-store clinic nurse practitioner prescribing, a pharmacist check is still made but an ethical issue is still present when it’s the in-store clinic nurse that decides where to send the prescription, not the patient. Also, it’s obvious that the more prescriptions written, the more profit can be made. But it could be at the patient’s expense since the more medications they take, the greater the risk of an adverse reaction.

I’m definitely not accusing Walgreens, and least of all the nurse practitioner, of any bad motives. But sending the prescription right to their pharmacy did raise a red flag for me.  With the growth of in-store clinics and expansion of services offered, it’s only a matter of time before some pharmacies, chain or independently owned, see opportunity in sort of a doctor dispensing operation in reverse.  With a pharmacy owning the clinic, employing the prescribers, doing the purchasing and deciding what drugs will be on the clinic formulary, the operation is also capable of inserting itself in ways that influence which drugs will be prescribed. We could see some enterprising owners capitalizing on this for profit, so this does bear watching.   


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Michael R. Cohen, R.Ph. President, Institute for Safe Medication Practices
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Check Up covers regional health news and a wide array of healthcare topics from pharmaceutical happenings to patient safety. Read about some of our bloggers here.

Portions of this blog may also be found in the Inquirer's Sunday Health Section.

Michael R. Cohen, R.Ph. President, Institute for Safe Medication Practices
Daniel R. Hoffman, Ph.D. President, Pharmaceutical Business Research Associates
Hooman Noorchashm, M.D., Ph.D. Cardiothoracic surgeon in the Philadelphia area
Amy J. Reed, M.D., Ph.D. Anesthesiologist and Surgical Intensivist in the Philadelphia Area
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