The Disintegration of Patient Rights in the American Corporate Pharmacy

by Emmett Murphy PayingthePrice.org

The Disintegration of Patient Rights in the American Corporate Pharmacy Patient rights are in danger in the United States, due to imposing government regulations, anticonsumer corporate practices and the transition of the pharmacist-patient relationship from personal and interactive to an automated, detached transaction at a pharmacy counter. The Omnibus Budget Reconciliation Act (OBRA), which passed in 1990, set federal standards for pharmaceutical practice and was designed to protect patients rights. OBRA mandates the offer to counsel patients about their prescriptions, also specifies the components of patient counseling. Most consumers are not even aware that they have patient rights, and as a result, they are not receiving the basic standard of care experienced by their parents and grandparents generations. Small, neighborhood pharmacies are disappearing, being replaced by mainstream, bigbox retailers. These corporate pharmacies, which are generally chain stores or embedded in large supermarkets, have many documented failures including inadequately trained employees, drug shortages and other problems that are endangering patients health. Related consumer complaints and reviews can be found at ConsumerAffairs.com. Even mom and pop pharmacies that can manage to survive are being squeezed economically and finding it difficult to provide high quality pharmacy care. Wal-mart, the worlds largest retailer, exacerbated this problem by introducing a Medicare prescription drug plan that imposes higher co-payments on seniors who choose to continue to use community pharmacies. Through this move, Wal-mart used its powerful position in the marketplace to force plan participants to abandon their

neighborhood pharmacy and fill their prescriptions at Wal-mart. But the giant retailer is on record for providing poor patient care and customer service. A 2010 national study of pharmacies by J.D. Power and Associates showed that patients gave Wal-mart retail and mail order pharmacies industry-low satisfaction ratings. Even as the retailer pours millions of dollars into marketing campaigns, the company continued to receive poor marks. The companys prescription drug plan policy may be endangering patients health through forced participation in this low-rated plan. Additionally, dispensing errors are more common at big-box stores. And these errors can be life-threatening. In Colorado, an employee at a grocery story pharmacy gave a pregnant woman a drug prescribed for someone else because the two patients had similar names. The pharmacy gave the woman a drug that is used to treat cancer, but also to terminate early-stage pregnancies, endangering her unborn child. In another instance, a customer administered a dose of an instant-release version of a strong pain medication to her young son. The medication was prescribed to be a time-extended release. The dispensing error put the child in a life-threatening situation without his knowledge. Also, big-box stores often have drug shortages, which can force patients to skip doses. The consumer advocacy website ConsumerAffairs.com has an entire forum dedicated to complaints specifically about Wal-mart pharmacies. You can view the complaints, which range from expired medication to short supplies, here: http:// www.consumeraffairs.com/rx/walmart_rx.html. Other complaint boards exist for large chain pharmacies such as CVS (http://www.complaintsboard.com/bycompany/cvspharmacy-a796.html) and Walgreens (http://www.consumeraffairs.com/rx/ walgreen.html). The overwhelming input on the complaint boards shows that the big box pharmacy model is not working for American consumers. An alternative to the faceless chain model are independent pharmacies that are accredited by international certification programs. We often get comments like Ive never spoken to a pharmacist before, said Lori Janeson, pharmacist founder and the owner of Jan Drugs, an accredited Canadian pharmacy. The way we think of it is that a pharmacy should be a service, not just a product sale, Janeson said. We feel the same economic pressures as other pharmacies, but still continue to provide good access to pharmacists at Jan Drugs, she said. A large percentage of patients filling prescriptions do not talk to their pharmacists. The type of personal service offered by pharmacies like Jan Drugs is becoming extinct, especially as patients dont know to demand it.

Plans Cited for Poor Customer Service The government is aware of problems with pharmacies and the breakdown of enforcement of rules violations. The Centers for Medicare & Medicaid Services has sanctioned Medicare prescription drug plans for providing poor customer service. CMS recently sent 651 warning letters for violations of standards for providing information on plans and 152 notices for violating standards for call centers and customer service. It submitted 318 requests for specific plans to improve business practices such as answering patients calls and submitting correct information to an online plan finder. The Centers taking action, such as suspending plans ability to enroll new beneficiaries for poor call center operations and other errors, illustrates the prevalence of shoddy practices. State Boards of Pharmacy Every year, consumers file thousands of complaints with state boards of pharmacy about pharmaceutical care. The National Association of Boards of Pharmacy, which represents state pharmacy boards in all 50 states as well as in D.C., Canada, Australia and New Zealand, acknowledges in its preamble that the standards of care for patients are eroding: Given that medications are an integral part of disease management, medication therapies and their delivery systems are becoming more complex, technological enhancements have improved the capabilities for patient monitoring, and entities motivated by economic gain are eroding standards of care, there is greater potential for harm to the public and a greater need for patients medication use to be managed by a licensed pharmacist and state regulatory agencies to aggressively enforce standards of care, the board states. State pharmacy boards field complaints about pharmacy treatment and care, such as errors in filling prescriptions and suspected misconduct by pharmacists, and the boards spend resources investigating errant pharmacies. As an example, Californias pharmacy board lists the following potential pharmacist misconduct: The pharmacist fails to counsel you about how to take a new prescription (or a prescription with changed instructions) and its possible side effects. A non-pharmacist employee is allowed to counsel you regarding your prescription The pharmacist is not present and your prescription is filled by a non-pharmacist The pharmacist fails to maintain the confidentiality of your prescription

California residents can file complaints about pharmacist misconduct here: http:// www.pharmacy.ca.gov/consumers/complaint_info.shtml. The board uses complaints to conduct investigations, and can suspend or revoke the license of a pharmacist or pharmacy. Texas has a similar procedure. The pharmacy board investigates consumer complaints and exercises its power to suspend or revoke licenses of pharmacists or pharmacies that are violating drug laws. Information about all state boards of pharmacy is available here: http://www.nabp.net/boards-of-pharmacy/. Pharmacist misconduct can lead to prescription errors, such as dispensing the wrong drug or dosage, refilling a prescription without authorization, filling a prescription with a generic instead of brand name drug without telling the patient, or using expired drugs. Patient Right to Consultation All patients have the right to consult with a pharmacist about their prescription. Under the Omnibus Budget Reconciliation Act (OBRA), a pharmacist is required to review drug therapy prescribed to patients to ensure that it is safe and effective. Pharmacists must consider factors such as over- or under-utilization, drug-disease interactions, drug-drug interactions, incorrect dosage or duration of treatment, drugallergy interactions, and clinical abuse or misuse. Additionally, OBRA states that a pharmacy patient must be offered the opportunity to consult with a pharmacist. Specifically, the law states that pharmacists must offer to discuss the medication with each patient or caregiver before a prescription is filled or delivered. According to OBRA, the pharmacist should discuss things that would be relevant or important according to their professional judgment, such as name and description of medication, how the medicine should be taken, dosage amounts, the duration of treatment, special directions for use, common severe side effects, potential interactions with other drugs, proper storage, and prescription refill information. Some states require a pharmacist to make the offer personally, whereas other states allow other personnel to make the offer. Waiver is Often Automated Because of the rise of the big-box pharmacy model, the offer for patient consultation is disappearing or is often veiled in procedure or technology.

Under OBRA, the offer must be made at the point of sale or point of distribution. This waiver has become automated, often whittled down to a question on the credit card pin pad, eroding the purpose of the legislation. A majority of states, 32, or 64 percent, only require counseling to be offered for new prescriptions, not for refills. Five states do not require the counseling to be face to face. Some states, such as Colorado, do not require pharmacists to consult with patients about new medications. Patients can waive their right to consultation, but to refuse it, a patient has to know the option exists in the first place. Many do not. At many pharmacies, the process of "refusing consultation with a pharmacist" has been automated, often distilled down to the credit card swipe pin pad. There is no explanation of the consultation and the patient rarely even encounters the pharmacist. The right to counsel is an informed right, but this practice has become automated and unrecognizable to the point that many patients do not know they are waiving it. These patients are bypassing an important opportunity to consult with a pharmacist about their drug therapy. For example, mail order pharmacies must provide a toll-free telephone number for patients to receive counseling, but this option is often overlooked. This is a problem because going through mail order pharmacies is the fastest-growing method for filling prescriptions. Patients should not be facing a one size fits all approach to receiving treatment, Lori Janeson said. Consumers are entitled to receive individualized, tailored care and instructions for their health. But patients are not aware of their rights, which ensures that their rights are eroded further. As part of our dedication to our clients, a licensed and professional pharmacist is also available Monday through Friday to provide free counseling and answer questions, even if the customer opts to buy medications elsewhere, Janeson reports. Only a handful of published opinions have been handed down addressing patients rights under OBRA. In a majority of cases, the court ruled in favor of the pharmacy not having a duty to its patients. As a result of these trends, Americans are not receiving the most basic of consultations with their pharmacist when they pick up a prescription. The lack of consultation endangers their health.

Research shows that strong relationships between pharmacists and patients enables positive treatment outcomes.

Patient Bill of Rights According to a code of ethics for pharmacists issued by the American Pharmacists Association, pharmacists have a moral obligation to help patients achieve the maximum benefit from their medications. Under the code, a patients well being is recognized as central to a pharmacists practice. A pharmacist is supposed to encourage patients to participate in decisions about their health, not dodge consultation opportunities. Also, a pharmacist must communicate with patients in terms that are understandable, meaning stating more than what is printed on a credit card swipe pad. Jan Drugs believes patients should have access to a pharmacist to answer questions about their prescription and receive instruction for safely taking the medication. This differentiates us from Wal-Mart and other big box stores, as well as many online pharmacies in both the United States and Canada, Jan Drugs owner Lori Janeson said. Were very proud of that distinction. As a pharmacy patient, you have the right to: receive considerate and respectful pharmacy care. obtain relevant, current, and understandable prescription drug information concerning medication therapy and treatment from pharmacists and other direct caregivers. discuss and request drug information related to your specific drug therapy, including possible adverse drug side effects and drug interactions. make decisions about your plan of care prior to and during the course of treatment and to refuse a recommended treatment or plan of care. know that all communication, discussion, and counseling will be conducted so as to protect your privacy. have all prescription records and discussion pertaining to your drug therapy will be treated as confidential, and that the pharmacists and pharmacy technicians will emphasize the confidentiality of your information to any parties entitled to review your medical information and records. receive competent counseling from a pharmacist to help you understand your medications and use them correctly.