90-Day Supply
We have spent a considerable amount of time ‘unpacking’ the New York Times article by Ellen Gabler entitled, “How Chaos at Chain Pharmacies is Putting Patients at Risk” that was originally published on January 31st. And, it is with good reason that this has consumed so much our conversation. It was one of those iconic articles that resonates down the hallway, as if someone has spilled all of the family secrets. In previous sessions, we have discussed the eye-raising structure of self-regulation in pharmacy, the questionable application of corporate pharmacy metrics, and the professional accusation of “crying wolf” when it comes to refill requests for our patients. The silence in the hallway lingers as we wait for a public reaction.
In the final analysis of this article, I would like to address one of the claims that, frankly, baffles me from both a professional and business perspective. I am referring to the article’s claim that pharmacists are inappropriately converting prescriptions over to a 90-day supply. The article points out a statement of concern about suicide accessibility by the American Psychiatric Association that goes as far as accusing one of the nation’s leading retail pharmacies of ‘routinely ignoring doctor’s explicit instructions to dispense limited amounts of medication to mental health patients’. The article further points to the corporate metrics that allegedly encourage persuasion of at least 55% of patients from receiving a 30-day supply to a 90-day supply.
So, before diving into the specifics of what that means either positively or negatively for patient care, let’s consider this purely from a business perspective for a moment. And, I must ask if any of this even make sense. Certainly, in a mail order setting where the transaction revolves solely around the prescription, that may make perfect sense. The pharmacy sells a three-month supply and spends the same amount of postage, supply, and personnel costs on that prescription that would otherwise be repeated twice if a 30-day supply were required. This reasoning assumes that the transaction associated with that prescription accounts for no other variables.
Retail pharmacies, however, have lots of glorious variables. Need I remind anyone of the shiny holiday candy on the walk back to the pharmacy? How about the glamorous greeting cards with prices approaching 10 bucks these days? The seasonal Santa Claus plush toy that burps to the tune of ‘We Wish You a Merry Christmas?’ You get the point. If, from a corporate viewpoint, we eliminate two visits to the pharmacy, we have also eliminated two opportunities to sell a burping Santa with a ten-dollar Christmas card attached. What I argue is this: Even from a corporate, money driven lens, this model does not make sense for a physical retail location. What other corporate initiative is designed to DECREASE foot traffic in the store… aside from this 90-day refill model?
Aside from the ‘financial lens’, we must also consider this from a ‘patient care’ lens. Prescribers have pointed to mental health drugs like lithium that have a narrow therapeutic index and a high propensity for toxicity. Such medications are frequently distributed to patients who are at an increased risk of suicide. Some argue that the ’90-day model’ is akin to handing these patients a loaded weapon. Also, one could argue that much could change in 90-days. Dosages may be increased, decreased, or discontinued altogether. Residual prescription vials filled with discontinued medications create an increased risk for inappropriate duplications in therapies.
So, the prescriber is in the driver’s seat here, right? Well, not necessarily… at least according to one Rhode Island psychiatrist highlighted in the New York Times article. This psychiatrist went as far as stamping all of his prescription pads with the marking ‘AT MONTHLY INTERVALS ONLY’. Still, the prescriber reports this notation is being ignored. As a pharmacist, I find this assertion surprising. Have we really gotten to the point of ignoring explicit prescriber instructions in favor of meeting a corporate metric? I certainly hope not.
In the end, I fail to understand why this is a battle for any of us to be in. Are we missing the bigger picture? This seems to be one of the areas where the ‘financial’ and ‘patient care’ lenses tend to align… and we are STILL missing the forest here for the trees. We have bigger fights to tackle. Of course, I am no corporate strategist here, but I do pick up prescriptions at the pharmacy… and, you very well may find those prescription vials stored in one of my home cabinets beside a Santa Claus merrily burping a classic holiday favorite.
[Author’s note: The article being referenced appeared in the New York Times on January 31, 2020. There are many points to unpack in ‘the’ article. Future postings will evaluate other aspects of this article. The original article, in its entirety, may be viewed here.]
