Simon Murray, MD

The number of independent pharmacies in the United States dropped from 23,106 in 2011 to 21,909 in 2017, according to 

I recently spent the day with Chris Castagna, RPh, an independent pharmacist who owns 3 stores in New Jersey. Owning more than one store can help with inventory and overhead costs, he said. Most independent owners are older, having been in business in the same community for many years. As I sat and talked, Castagna never stopped working. He was always on his feet, darting between the computer, the phone, and the counter.

Castagna got into the independent pharmacy business, he joked, because “if I had to work for an idiot boss, at least the idiot I could work for would be myself.”

Castagna decided about 15 years ago to expand his array of pharmacy services, offering home delivery, providing vaccines, and offering more professional counseling. He noted the great lengths he has gone over the years to differentiate himself from the competition, notably, providing great customer service and sound advice for clients. These efforts have paid off, in the form of him being able to buy 2 more stores in a large suburban area, one of which services a retirement community.

At one point in our discussion, Castagna’s assistant interrupted us to say there was a customer at the counter who had a letter stating he had to go to one of the local chains. He had been a customer for 30 years. Castagna had seen this man’s children grow up, and had been there for him during several illnesses. The man felt badly but felt he couldn’t afford to not to go to the retail chain as directed. Castagna said he’s never gotten used to losing patients like that but had no choice. That practice, and the fact that many people had moved across the river from New Jersey to Pennsylvania because of the tax structure has cut into his business in recent years, he said.

Complicating the independent pharmacy business, Castagna discussed pharmacy benefit manager (PBM) involvement with drug pricing. Their extraction of fees from the pharmacy companies keeps the price of brand name drugs high. Payers don’t care if prices are high, they just, in turn, raised copays, he said. The high prices made it difficult to keep in stock all of the new medicines because it was money just sitting on the shelf waiting for a customer to fill a prescription. Occasionally, he said, he would lose a customer who couldn’t wait a day for him to order the medicine.

PBM extracting fees from community pharmacists, coupled with the fact that generics are priced so low, are driving pharmacy profits lower, Castagna noted. Generic wholesalers with whom he had arrangements dictated the prices after they skimmed off the profit from the generic medicines. As an independent he could join a group of other independents who would negotiate prices with the distributors, but they didn’t have the clout of the big chains. Also, the cost to fill a prescription dropped from the price of about $11, which was the Medicaid rate 5 years ago, to now .40 to .60. The people that did the negotiating charged him $1.50 cents for each prescription filled. On many generics he lost money.

During this point in our conversation, the pharmacy phone rang. It was a customer who wanted to know why she got a letter saying her blood pressure pills were “poison.” He explained the situation-due to the disclosure of certain cancer-causing substances in certain blood pressure medications, many have been recalled--and advised the customer he would take them back. He hung up and told me that China now controlled all the chemicals necessary to make drugs and controlled the generic market, along with India. Castagna said he felt a slight doubt about the quality of generic drugs and the FDA’s oversight on these generics, but he noted there was probably no way to reverse that, since China had most of the rare earth minerals essential to drug making.

He had been doing compounding for a while but recent laws had made that financially prohibitive because of the cost of quality control that had been imposed. He eventually lost one of his two helpers because he couldn’t pay her so he was doing most of the work himself. 

Our interview was interrupted by a patient that questioned Castagna about why her pill color had now switched from green last month to yellow this month.  He had to change brands due to cost, he said. She didn’t understand why everything had to be so complicated. Neither did I. As we spoke his computer kept printing out reams of paper with electronic prescriptions. Some couldn’t be filled for incomplete information, some needed prior authorization, a process that had been increasing of late. He had to call a local physician  and be put on hold for 5 minutes before he could talk to anyone. His fax machine wasn’t working and Verizon was already 2 hours late in coming out to repair the phone line. All the while, we talked he paced back and forth, counting pills, answering the phone, talking to customers.

I ended our interview by asking him if he would go into independent pharmacy and start all over again. Without hesitation he said, “Hell would have to freeze over first.  At least I had some good years, and my kids are through college, and if I had to work for an idiot, at least it was me.”

Despite his own challenges, Castagna said that motivated pharmacists looking to get into independent pharmacies can thrive. He encouraged use of technology and diversifying inventory to more carefully curtail care for each customer.

Of note, Castagna mentioned stocking more high end vitamins and cosmetics, as well as cannabidiol, which has proven itself to be a big seller and is helping pay the bills. Educating one’s self on what these compounds offer in terms of safety and efficacy is key, he explained.

Simon Murray, MD, is an internist based in Princeton, NJ and the chief medical officer for MJH Life Sciences. The piece reflects his views, not necessarily those of the publication.
	
	Healthcare professionals and researchers interested in responding to this piece or contributing to Drug Topics® can reach the editorial staff at jbarrett@mjhlifesciences.com

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Simon Murray, MD, recently spent the day with Chris Castagna, RPh, an independent pharmacist.

Independent Pharmacy: A Day in the Life

When I started practicing medicine some 35 years ago, almost every pharmacist in the community sent me a bottle of liquor or candy as a welcome gift and usually extended an offer for discounts in their store. In return, I visited all of them and introduced myself. Things have changed, names have changed, and communication has dwindled. Mutual respect has been replaced by suspicion and even unkind words toward each other.  That must change. Life is hard enough, and we need to treat each other as colleagues in this noble of all professions. Change starts with improved communication.

Practicing medicine as well as pharmacy has gotten to be much more complicated despite the dozens of ways the modern miracle of technology has promised to make our lives easier. Despite all the new technological “time savers” that now exist to “improve our productivity” none of us, pharmacists or physicians, are doing a great job at effectively communicating with each other. If we are interested in the well-being of patients, we are going to have to make the time to communicate better as professions.

As a practicing internist there are a few things that I feel could help physicians and pharmacists communicate better:

When the prescription is written for a patient that is not in stock or carried by that pharmacy I would prefer to be called while the patient is still in the store rather than have the patient be told “go back to the doctor and have him change this.” This causes undue delay in treatment and a great deal of back-and-forth phone calling that is totally unnecessary. For the past 12 years I have given patients and colleagues my cell phone number and I find it much easier to communicate in this manner than having the patient go through the office or an answering service. With the advent of electronic prescribing, things have become a little bit easier but nothing is perfect, and I find that even now about 1 out of 5 electronic prescriptions somehow gets lost in the ether. If there was a way to make my cell phone available to all pharmacists, I would relish getting called personally rather than dealing with messages.

2. Have a question about my recommendation? Discuss it with me. 

When Keflex was released, it caused allergic reactions in 5% to 15% of patients who were penicillin allergic. We have since learned that all the first-generation cephalosporins can cause cross-reactivity with penicillin. However, there is no convincing evidence that second- and third-generation cephalosporins cause a cross-reactivity with penicillin in most patients. To that end, I recently prescribed Ceftin for a patient who might have been allergic to penicillin. The patient was told by his pharmacist not to fill it because it might kill him. In that circumstance a much more professional approach would have been for the pharmacist to have called me and discussed it with me. I certainly respect the opinion of pharmacists and their knowledge and they have saved my neck more than once with regards to making mistakes in prescriptions. In this instance, however, the pharmacist was incorrect and made me look like I was careless. A simple phone call discussion could have resolved the issue. Instead the patient had to contact my office and I had to explain to him that I am aware that first-generation cephalosporins can cause cross-reactivity but the drug I prescribed was not a first-generation cephalosporin.

3.  Advise me and the patient on cheaper medication alternatives. 

I wish that pharmacists would let me know when one of my prescriptions could be filled by a cheaper or more appropriate alternative. I recently wrote a prescription for an allergic conjunctivitis for FML SOP ointment that used to cost a few dollars but now is $200 for five grams. I had no idea. I would have gladly taken advice on a cheaper alternative from a pharmacist. Shame on me for not knowing the cost of drugs, but some of the generics really shot up in price without my knowledge. I understand there was a gag clause in place that limited pharmacists from telling patients that certain drugs cost less when purchased outside of insurance, but I was unaware that it applied to the over-the-counter medicines.

4. Communicate with me about possible drug-seeking behavior. 

I would like to know if there are any suspicions about drug seeking behavior on the part of patients, or if a pharmacist feels a prescription for a controlled drug is inappropriate or perhaps violated DEA regulations. I would much prefer a call from my local  pharmacist rather than have him or her refuse to fill it or report me to the medical board. In certain instances, prescriptions are needed that exceed usual doses. In other instances, I may not know the regulation and it could have been an honest mistake. Those cases should be few and far between, and I’m not talking about the unprofessional prescribing behavior we witnessed in the last decade by a handful of dishonorable or dishonest doctors. Many years ago, I wrote a prescription for Ritalin for a teenager. The patient had changed the number to be dispensed from 30 to 300. I made the error of not writing out the word “thirty.”The pharmacist called me on the phone and asked me what I wanted him to do. I thanked him, agreed that he shouldn’t fill, and I asked him to send the boy back to my office. When the patient returned, I told him he was going to drug rehab that night or I would call the police. I wouldn’t hear one word of his excuses and insisted. He checked into a local drug rehab that night and signed himself out a few days later never to be seen again, but we at least did our best to help him.

Initiating conversation takes time and effort. It also involves taking a certain risk. Not all physicians are reasonable or willing to accept advice. I apologize for their ignorance as well as my own. We do need your help, but if we are too ignorant to accept it than its out of your control and you did the right thing. Physicians must also show the same flexibility and respect to pharmacists and I would welcome your comments to these suggestions and tell me how I could make your lives easier. No one said it would be easy to establish a dialogue in this crazy rapid paced world we practice, but I feel it would enhance the lives of our patients and our professions.

Initiating conversation takes time and effort.