Eye on ethics: Is a two-tiered pharmacy system inevitable?

Q: To keep a small pharmacy chain profitable and continue serving patients, the CEO is considering remote prescription verification (transmitting data to pharmacists at slower stores), dispensing kiosks for after-hours Rx pickup, Internet refills, and outsourcing patient phone calls to a clinical service provider. How could there be anything wrong with using technology to maintain market share?

A: It all depends on what you are selling! Unlike bread or milk, prescriptions can't be purchased anywhere from just anyone. The pharmacist's knowledge, assurance of quality, accurate dispensing, and appropriate information about the use of the drug by the patient are implicit in the sale of every prescription.

The business press has described the widening income disparities in the U.S. population. As the middle and lower classes lose ground, many retailers adapt by selling lower-quality products and providing less service, in the well-named "race to the bottom." Other businesses shift their products, services, and prices to cherry-pick customers with higher incomes. This creates a two-tiered system with distinct differences in quality of service, quality of products, and pricing.

However, disease and illness observe no socioeconomic class divisions. Consider the future of two patients, both diabetics with similar patterns of disease. One patient goes to the convenience model pharmacy, while the other goes to the full-service pharmacy, where pharmacists are required to maintain their clinical education to support many professional services, and customer service is structured around patient care.

The Danish philosopher Soren Kierkegaard said, "Life can only be understood backwards, but it must be lived forwards." The difference in care that these patients receive may be invisible for many years. If the first patient is eventually hospitalized, retroactive DUR might reveal the trail of unasked questions, OTC blunders, and compliance problems that often accelerate disease progression. The second patient, who receives consistent, face-to-face intervention from pharmacists in a setting that facilitates positive pharmacist-patient relationships, is likely to experience more positive outcomes.

If the pharmacist's job is "reverse-engineered" down to small bits of information and the patient receives this "care" in fragments or secondhand, does he still need a pharmacist? Some patients don't think so. An estimated 10% of the drugs taken by U.S. patients right now are obtained from beyond our borders with no interaction between the patient and a U.S. pharmacist.

Can technology be successfully managed to avoid a two-tiered service level in pharmacy? Each innovation may create a new way to reach out to patients, or a new way to isolate them from the pharmacist. Each company's mission statement, recruiting system, and quality control should agree; if professional services are promised, then patients should always have easy access to a pharmacist and convenience should never overtake professional care.

Each change considered in pharmacy should provoke these questions: How will this change impact patient care? Will this new (technology, program, service) benefit the patient? If a new program, convenience, technology, or staffing pattern is detrimental to patient care, it should be reevaluated and adjusted, or it should be changed.

THE AUTHOR has practiced long-term care and community pharmacy in Oregon for more than a decade and has served on numerous professional and community boards.

Disclaimer: This column highlights ethical situations that often occur in pharmacy practice. It is designed to stimulate discussion on how to deal with these situations and is not intended as legal advice. Pharmacists who need immediate assistance should consult their attorneys, employers, state boards of pharmacy, and state and federal laws.